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📋 Patient Identification

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📊 Admission Details

🎤 Voice Dictation Sections

Use the prompts on the left as a guide. Click the microphone to record your dictation on the right.

👩‍⚕️ Obstetric History

📝 Structured Form Fields:
  • Consanguinity: Yes/No
  • Medical Problems: List conditions + medications
  • G_P_L_A: Gravida, Para, Livebirth, Abortion values
  • Previous Deliveries: Year, Place, Delivery type (Vaginal/LSCS/Instrumental/Breech), Complications, Gender, GA (weeks), Birth Weight (grams), Health status, Details

🤰 Pregnancy

📝 Structured Form Fields:
  • Conception: Spontaneous/Medical ART/ART
  • ART Details: Type, Embryo Transfer, Place
  • Dates: LMP, EDD by USG, EDD by Dates
  • Mother's Blood Group
  • Screening: HIV, HepatitisB, VDRL status
  • Antenatal Care: Booked (Yes/No), Place of Booking, Supervised (Yes/No), Place of Supervision

🤰 Pregnancy (Continued)

📝 Structured Form Fields:
  • ANC Visits: Number and frequency
  • Pregnancy Complications: List any issues
  • Medications/Supplements: Taken during pregnancy
  • Scan Findings: Key ultrasound findings, anomalies

⚡ Labour

📝 Structured Form Fields:
  • Onset: Spontaneous/Induced
  • Duration: Hours of labor
  • ROM: Rupture of membranes timing
  • Liquor: Clear/Meconium stained/Blood stained
  • Complications: Fetal distress, prolonged labor, etc.

👶 Delivery

📝 Structured Form Fields:
  • Mode: Vaginal/LSCS/Instrumental
  • Presentation: Cephalic/Breech/Transverse
  • Fetal Distress: CTG findings
  • Anaesthesia: Type used
  • DCC: Delayed cord clamping (Yes/No)
  • Cord Blood Gas: pH, Base excess
  • PROM: Duration if applicable

📊 APGAR Scores

📝 Structured Form Fields:
  • 1 minute: Score
  • 5 minutes: Score
  • 10 minutes: Score (if needed)
  • 15/20 minutes: Score (if needed)
  • Components: Colour, Heart Rate, Reflex Irritability, Muscle Tone, Respiratory Effort

🚨 Resuscitation Details

📝 Structured Form Fields:
  • Initial Steps: Drying, stimulation, positioning
  • Facial O2: Flow rate, duration
  • CPAP: Pressure, duration
  • Bag-Mask Ventilation: Duration, FiO2
  • Intubation: ETT size, depth
  • PPV: Duration, pressures
  • CPR: Duration
  • Drugs: Adrenaline, NS bolus

📋 Essential Details

📝 Structured Form Fields:
  • Initial Examination: Findings at birth
  • Malformations: Any congenital anomalies
  • ICT/DCT: Results
  • Background: Relevant family/social history
  • Plan: Immediate management plan

🏥 Post-Resuscitation Care

📝 Structured Form Fields:
  • Monitoring: Vitals, SpO2, glucose
  • Temperature: Management, servo control
  • Feeds: First feed timing, type
  • Respiratory Support: Ongoing support details

🛏️ Admission Details

📝 Structured Form Fields:
  • Reason: Primary reason for admission
  • Time: Time of admission
  • Source: Delivery room/OT/Transferred
  • Referring Unit: If transferred

🔧 Procedures

📝 Structured Form Fields:
  • Line Insertion: Type, site, time
  • Surfactant: Type, dose, time
  • Umbilical Catheter: UVC/UAC, depth
  • Exchange Transfusion: If applicable

🩺 Diagnosis

📝 Structured Form Fields:
  • Working Diagnosis: Primary diagnosis
  • Differentials: Other possible diagnoses

🔍 Summary of Examination

📝 Structured Form Fields:
  • General Survey: Activity, colour, cry
  • CVS: Heart sounds, murmur, pulses
  • RS: Air entry, retractions, grunting
  • Abdomen: Distension, organomegaly, bowel sounds
  • CNS: Tone, reflexes, fontanelle
  • Skin: Colour, rashes, birthmarks
  • Musculoskeletal: Limbs, spine, hips

📋 Saved Proformas

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