Gynecological exam and antenatal care — in one chart, kept confidential.

The visit is made of OB/GYN sections: complaint, history, vital signs, gynecological status, pregnancy, diagnosis and treatment plan. Complaint, history, status, pregnancy and plan also have a free-text field, so doctors can write the way they are used to.

• History: menstrual (menarche, last period, cycle), obstetric (pregnancies, births, abortions, caesarean sections, ectopic pregnancies), contraception, cervical screening (last smear, result, HPV), family history
• Gynecological status: breasts (right and left separately), external genitalia and prolapse stage (POP-Q), speculum examination and samples taken, bimanual examination, discharge; a normal status fills in with one click
• Diagnosis with an ICD-10 code, from a selection for gynecology and pregnancy; a visit can't be completed without complaint and diagnosis
• A plan with procedures, investigations, contraception, pregnancy supplements, screening and a delivery plan, and follow-up; visit summaries and referral letters as PDFs

In a dedicated pregnancy section the doctor records gestational age (weeks and days) and how it was dated, the estimated due date, the number of fetuses, fundal height, fetal heart rate and movements, presentation, swelling, urine protein, Rh status and risk factors. At the next visit the previous visit's section copies over in one click — only what changed needs updating. The Bishop score is scored during the visit and saved to the patient's chart. The pregnancy section also appears in the visit-summary PDF.

The patient's chart has "pregnant" and "breastfeeding" marks. When one is set, substances contraindicated in pregnancy or breastfeeding are flagged with their own warning as a prescription is written, and allergies and drug interactions are checked including medicines other clinics prescribed. These safety facts are open to every clinic treating her, regardless of consent. The visits themselves are seen by another clinic only with the consent the patient gave to that clinic. Every opening of the chart is written to the audit log, and lock-screen notifications and email subjects never carry clinical details.

If your clinic switches it on, the patient fills in a questionnaire in the portal before the visit — about 5 minutes: the reason for the visit, complaints, last period and cycle, pregnancies and births, contraception, last Pap test, a current pregnancy and how far along it is, conditions, operations, medicines, allergies and family history. If she reports heavy bleeding, sudden severe pain or danger signs in pregnancy, the portal tells her straight away to call 112; bleeding after the menopause gets a reminder to be sure to tell the doctor. Nobody reads the questionnaire before the visit — the doctor sees the answers during the visit and moves them into complaint, history and the pregnancy section in one click; what the doctor wrote is never overwritten.

When the visit is completed, the doctor shares a plan with the patient: the follow-up date, tasks and warning signs. There are ready-made lists for pregnancy, after giving birth, and bleeding and pelvic pain, so the patient gets in writing when to call 112 and when to contact the clinic. At the doctor's request the patient keeps a blood-pressure or weight diary in the portal and decides whether to share it with your clinic; nobody watches it in real time. Unbooked follow-ups land on a recall list, and a freed slot is offered to the waitlist. Cash-desk shifts, discount limits, voluntary insurance registries and doctor commissions live in the same system.