Record a birth

Record a birth is the full course-of-care form — every registry field, laid out in nine sections, with a lifecycle you can save as a draft and finish later, then complete and lock when the record is final. Reach it from Add Birth in the registry sub-nav, or from the Births log when you need more than the quick drawer.

The page opens under the heading Add a birth record: “Enter a full birth record across every section. Save a draft and finish later, or complete and lock when the record is final.”

The lifecycle strip

A banner at the top of the form shows the record’s current state and the path it follows: Draft → Enrolled → Complete → Locked. The full lifecycle — including amendments and voiding — is covered in Records & amendments.

The nine sections

1. Patient — attach the birth to the mother’s patient record. Search by exact first or last name and choose Use, or Add a new patient inline with Add & attach.
2. Mother & demographics — maternal age, residence ZIP (first 3), race, ethnicity, education, marital status, primary payer.
3. History & risk — parity, gravidity, pre-pregnancy BMI, prior cesarean count, and flags such as Prior cesarean, Chronic hypertension, Pre-existing diabetes and TOLAC attempted.
4. Antepartum care — gestational age at care entry, prenatal visit count and adequacy, prenatal care site, GBS status, smoking before and during pregnancy.
5. Pregnancy, labor & intrapartum — labor onset, ROM method and time, fetal monitoring, pain management, Mode of birth, birth position, induction indication, cesarean type, MD involved; the three stage-duration boxes and the placenta time; and flags for induction, augmentation, doula present, delayed cord clamping, shoulder dystocia and STAT / emergency cesarean, with Induction agents and Augmentation agents where they apply.
6. Newborn(s) — one card per baby; choose Add newborn for a multiple. Each records date & time of birth, sex, gestational age, birth weight (enter lbs / oz or grams — grams is the stored value), the 1/5/10-minute Apgar scores, and newborn flags.
7. Transfers of care — choose Add transfer for each transfer, with its type, destination, reason and whether it was an Emergency. Shows “No transfers recorded.” when there are none.
8. Outcomes, place & attendant — Intended place and Actual place of birth, Attendant type, estimated blood loss band, perineal status, breastfeeding at discharge and at six weeks, and maternal-outcome flags.
9. Reference & consent — your own chart number, a mother name/identifier used only to detect duplicates and never stored, the consent scope and whether prospective consent was captured at intake, and the Practice birth / Count birth record flags.

Saving: draft, complete, lock

The actions at the foot of the form follow the lifecycle:

• Save draft — keeps the record editable; use it to finish later.
• Complete — marks the course of care complete once its outcomes are known.
• Submit and print — completes the record and opens its print sheet in one step.
• Lock record — appears once a record is Complete; locking freezes the record so it can afterwards be changed only by amendment.

Once a record is locked, the form shows a “This record is locked” notice and the only save action is Save amendment, which cuts a corrected version and keeps the original on file. See Records & amendments.

Terminology

The quick drawer and this form use different words for the same things, because each mirrors the source it came from:

• The drawer says Babies; this form says Newborn(s).
• The drawer’s location field is Site; this form records Intended place and Actual place of birth.

EHR pre-fill

When the form is launched from an EHR (a SMART on FHIR launch), the patient’s clinical data is mapped onto the record and the form arrives pre-filled — often inside an EHR iframe. Review the pre-filled values, complete the remaining sections, and save as usual; the record lands in your signed-in practice. For how the EHR launch and pre-fill work, see SMART on FHIR (EHR launch).

Next steps

• Records & amendments — lifecycle, corrections and revision history.
• Births — the quick drawer on the Births log.