OB-GYN EHR and practice management software handling obstetric continuity and gynecologic complexity
Obstetrics requires prenatal visit tracking, pregnancy complication monitoring, and delivery coordination across nine months. Gynecology involves preventive care, surgical procedures, and hormone management requiring precise documentation. Generic EHR systems lack pregnancy templates and global OB billing logic. Harris CareTracker delivers practice management software built specifically for OB-GYN EHR workflows where prenatal care continuity determines outcomes and accurate global billing protects revenue.
Why Choose Us?
HIPAA Compliant EHR with Obstetric and Gynecologic Templates
Automated Global OB Billing
Preventive Care & Quality Tracking
Prenatal Care Documentation Supporting Continuity and Outcomes
Obstetric care spans nine months requiring systematic tracking. Initial prenatal visit establishes baseline. Routine visits monitor maternal and fetal wellbeing. Complication documentation guides intervention. Delivery summary completes pregnancy record.
Harris CareTracker obstetric workflows ensure continuity from first visit through postpartum care.
First prenatal visit establishes pregnancy dating, confirms viability, assesses maternal health, identifies risk factors, and plans prenatal care schedule. Documentation supports global OB billing and risk appropriate care.
Templates capture last menstrual period, estimated due date calculation, ultrasound dating when available, obstetric history including prior pregnancies and outcomes, medical history affecting pregnancy, medication review, physical examination, and initial prenatal labs ordered.
Initial OB visit documentation:
- Pregnancy dating with EDD calculation from LMP or ultrasound
- Gravida and para status with detailed pregnancy history
- Previous pregnancy complications and outcomes
- Medical conditions affecting pregnancy risk
- Current medication review for pregnancy safety
- Physical examination including pelvic and breast
- Prenatal lab ordering with gestational age-appropriate tests
- Genetic screening discussion and consent
- Prenatal care schedule establishment
- Patient education on warning signs
Complete initial documentation establishes baseline supporting global OB billing submission after delivery.
Routine prenatal visits follow predictable pattern. Weight, blood pressure, urine dipstick, fundal height measurement, fetal heart tones, symptom screening, and interval history. Flowsheet format displays trends efficiently.
Pregnancy flowsheet shows visit dates vertically with measurements across rows. Weight gain trending. Blood pressure patterns. Fundal height growth curve. Fetal heart tone documentation. Glucose screening results. Group B strep status. All prenatal data visible at glance.
Prenatal flowsheet features:
- Visit date with gestational age calculation
- Maternal weight with total gain from baseline
- Blood pressure trending identifying hypertension
- Urine protein and glucose results
- Fundal height measurement with growth curve
- Fetal heart tones with rate and location
- Fetal movement assessment
- Symptom screening for complications
- Lab results including glucose, CBC, antibody screen
- Ultrasound findings summary
Flowsheet format improves visit efficiency. Trends visible immediately. Abnormalities surface quickly. Documentation time reduces while completeness improves.
High risk pregnancy conditions require detailed documentation. Gestational diabetes, preeclampsia, preterm labor, intrauterine growth restriction, and other complications need monitoring and intervention documentation supporting medical necessity.
Templates capture complication diagnosis, severity assessment, treatment plan, maternal and fetal monitoring, and response to intervention. Serial documentation shows disease progression or improvement.
Complication management documentation:
- Complication diagnosis with onset timing
- Severity grading using standardized criteria
- Maternal symptoms and objective findings
- Fetal assessment including growth and wellbeing
- Treatment initiated with medication or intervention
- Monitoring frequency and testing schedule
- Specialist consultation when indicated
- Hospital admission criteria and planning
- Delivery timing discussion based on condition
Complication documentation supports medical necessity for increased visit frequency, additional testing, and early delivery when indicated.
Delivery documentation captures labor course, delivery method, complications, newborn status, and immediate postpartum care. Complete delivery summary triggers global OB billing submission.
Template includes labor admission time, cervical dilation progress, rupture of membranes timing, delivery method vaginal or cesarean, anesthesia type, delivery complications, estimated blood loss, placenta delivery, perineal repair if applicable, newborn Apgar scores, and immediate postpartum stability.
Delivery documentation triggers:
- Global OB charge generation after delivery completion
- Antepartum visit bundling into global fee
- Delivery code selection based on vaginal versus cesarean
- VBAC documentation when applicable
- Complication coding affecting reimbursement
- Multiple gestation delivery coding
- Postpartum care inclusion in global period
- Separate billing for complications outside global package
Delivery documentation completion triggers global OB billing. All antepartum visits bundle automatically. Delivery and postpartum care bill as single global fee.
Well Woman Care and Gynecologic Problem Management
Gynecology encompasses preventive care, contraception management, abnormal bleeding evaluation, pelvic pain assessment, and surgical procedures. Each area requires specific documentation supporting appropriate coding and medical necessity.
Annual Well Woman Examination Documentation
Well woman visits include breast and pelvic examination, pap smear when indicated, STI screening, contraception counseling, and preventive health discussion. Preventive visit coding differs from problem visit coding affecting patient cost sharing.
Templates separate preventive components from problem management. Age appropriate screening captures. Pap smear indication documents. Contraception discussion notes. Preventive counseling topics record.
Well woman visit documentation
- Age appropriate preventive screening discussion
- Breast examination findings
- Pelvic examination with cervix visualization
- Pap smear collection with indication and method
- HPV testing when co tested
- STI screening discussion and testing
- Contraception review and counseling
- Preventive topics including bone health and vaccines
- Problem identification if additional issues addressed
- Preventive versus problem visit code assignment
Accurate preventive coding prevents patient balance bills from incorrect problem visit coding. Templates ensure appropriate code selection.
Contraception Management and Counseling
Contraception counseling, prescription, and device placement require documentation supporting medical necessity and informed consent. Method selection discussion. Risks and benefits explanation. Alternative options presentation. Patient choice documentation.
Contraception documentation features
- Current contraception method and satisfaction
- Contraception goals and preferences discussion
- Prescription or device placement documentation
- Billing code selection for counseling versus procedure
IUD and implant placement bill separately from office visit. Documentation supports procedure medical necessity and proper coding.
Gynecologic Surgery Documentation and Global Period Management
Gynecologic procedures including hysterectomy, oophorectomy, myomectomy, and minimally invasive surgery require operative documentation and global period tracking. Post operative visits within global period cannot bill separately except for unrelated conditions.
Operative notes capture preoperative diagnosis, procedure performed, surgical approach, findings, complications, specimens, and post-operative plan. Templates guide complete documentation supporting code selection.
Surgical documentation includes:
- Preoperative diagnosis and indication
- Surgical approach laparoscopic, vaginal, or abdominal
- Procedure details with anatomical structures addressed
- Intraoperative findings including pathology discovered
- Complications or unexpected events if any
- Estimated blood loss and transfusion if required
- Specimen documentation sent to pathology
- Closure technique and post-operative instructions
- Global period assignment based on procedure
Complete operative documentation supports appropriate CPT code selection and medical necessity justification.
Gynecologic surgeries include 10- or 90-day global periods. Post operative visits during global period bundle into surgical fee. Billing separately triggers denials. Unrelated problems during global period require documentation proving separate issue.
Automated global period tracking alerts when visits occur during active global periods. Unrelated diagnosis prompts modifier 24 consideration. Documentation guides proving visit addressed condition unrelated to surgery.
Global period management:
- Post operative visit alerts during active global periods
- Unrelated diagnosis identification for modifier 24
- Complication visit documentation within global period
- Return to OR coding with modifier 78
- Staged procedure billing with modifier 58
- Global period calendar showing active periods by patient
Global period compliance prevents denied claims and audit risk while ensuring legitimate exceptions bill correctly.
OBGYN Billing Handling Global Packages and Preventive Care
OBGYN billing complexity includes global OB packages bundling nine months of care, preventive visit coding, surgical global periods, and procedure billing. Each element creates denial risk when handled incorrectly.
Harris CareTracker automates OBGYN billing complexity preventing common errors.
Document OBGYN Encounters During Patient Care
Obstetric visits require both hands for fundal height measurement and fetal heart tone assessment. Pelvic examinations prevent simultaneous typing. Traditional charting happens after examining patients, creating documentation backlog.
Amplify by Harris CareTracker captures OB-GYN EHR encounters through ambient listening. Record the visit. Verbally document examination findings while examining patient. AI structures into OBGYN note format. Review and finalize in minutes.
Routine prenatal visits follow systematic pattern. Interval history. Vital signs. Fundal height. Fetal heart tones. Symptom screening. Patient education. Documenting while examining optimizes efficiency.
Ambient listening captures prenatal assessment verbally. State weight and blood pressure. Verbalize fundal height measurement. Note fetal heart tone rate and location. Discuss symptoms. AI organizes into prenatal flowsheet format.
Pelvic and breast examinations require focus on physical assessment. Describing findings verbally during examination enables documentation without interrupting clinical flow.
Speak examination findings while examining. Breast examination results. External genitalia appearance. Speculum examination with cervix visualization. Bimanual examination with uterine size and adnexa assessment. AI captures and structures appropriately.
Complete gynecologic examination documentation without stopping examination to type. Clinical flow maintains while documentation happens simultaneously.
Annual well woman visits cover multiple topics. Preventive screening discussion. Contraception counseling. Sexual health questions. Menstrual pattern review. Examination findings. Recommendations and planning.
Ambient listening captures comprehensive discussion. Patient responses to screening questions. Contraception preferences. Health concerns raised. Examination findings. Recommendations provided. AI organizes by preventive visit structure.
Complete well woman documentation in fraction of traditional time. Preventive components capture correctly supporting accurate coding.
OB-GYN EHR and Practice Management Built for Obstetric Continuity and Gynecologic Complexity
Generic software ignores OB-GYN EHRreality. Prenatal care lacks systematic tracking. Global OB billing requires manual intervention. Preventive visit coding creates patient complaints. Gynecologic templates miss specialty workflows.
Harris CareTracker eliminates these problems. Pregnancy flowsheets track prenatal care systematically. Global OB billing automates after delivery. Preventive coding accuracy prevents patient bills. Amplify ambient listening documents examinations during patient care.
Stop fighting software designed for primary care. Start operating with infrastructure built for obstetrics and gynecology.
What Our Customers Say About Us
We chose Harris CareTracker for our office because of its cost-effectiveness and since changing to them, we have seen a significant increase in our monthly savings. The standout feature has been the excellent customer support and training!
It’s really easy to use Harris CareTracker Practice Management. Very easy to learn.
We have used Harris CareTracker in our practice for 5 years, and it has been a wonderful experience. The trainers and on-going support teams are knowledgeable, accessible, and quick to respond to queries. They provided easy-to-follow step-by-step guidance for using the software. They never failed me. I highly recommend CareTracker for practices of any size.
Get Started Today
Connect With Us
Where here for anything you need, just drop a line and we’ll get back to you.