AI Scribe for OB/GYN
Transcribe Health drafts your prenatal, gynecologic, and well-woman notes while you work, so the dates, exam findings, and plan are on the page before you leave the room.
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OB/GYN documentation, from prenatal care to the annual exam
OB/GYN is really three clinics running out of one schedule. Prenatal care is longitudinal: the same patient comes back every few weeks, and each note has to carry forward the dating, the growth, the fetal heart rate, and the lab and ultrasound results, all pinned to an accurate gestational age. Get the GA wrong and the whole plan drifts.
Then there is gynecology, where a single afternoon can move from an abnormal bleeding workup to a contraception counseling visit to an abnormal Pap follow-up, each needing its own history, exam, and assessment. And there is well-woman care, which looks routine but has to document screening decisions (Pap and HPV interval, mammography, bone density, STI testing) that get audited later.
Transcribe Health listens to the visit, or to your narration after a procedure, and drafts a note that puts the numbers where they belong: GA and EDD, fundal height, fetal heart rate, G/P, cervical exam, Pap and HPV results, and the plan behind each. You read it and sign. Nothing is filed without you.
Documentation Challenges in OB/GYN
- 1
Keeping the prenatal flow sheet current across visits: gestational age, fundal height, fetal heart rate, weight, blood pressure, and the results of dating ultrasounds and lab screens
- 2
Switching between an obstetric follow-up, a problem-focused gyn visit, and a well-woman exam in a single clinic, each with its own note structure and its own set of numbers
- 3
Writing up procedures and deliveries (colposcopy, IUD or Nexplanon placement, vaginal or cesarean delivery) with the operative detail that billing and chart review expect
How Transcribe Health Helps OB/GYN
Prenatal Flow Sheet Capture
Pulls the gestational age, fundal height, fetal heart rate, and vitals from the visit into the running prenatal record, so the flow sheet stays current without retyping.
One Note Per Visit Type
Recognizes whether you are doing an OB follow-up, a gyn problem visit, or an annual exam, and drafts the note in the format that visit needs.
Procedure and Delivery Reports
Turns your narration after a colposcopy, IUD placement, or delivery into a structured report with the findings and technique documented.
A prenatal note, captured in real time
An abridged routine prenatal visit at 28 weeks with the one-hour glucose screen, drafted the way you would see it before signing.
31-year-old G2P1001 at 28 weeks 2 days by an 8-week dating ultrasound, here for a routine visit. Reports good fetal movement. No contractions, no vaginal bleeding, no leakage of fluid. No dysuria. Mild lower back ache, no headache or visual changes. Prior pregnancy was a term vaginal delivery. Taking prenatal vitamins daily.
BP 116/70, weight 74.8 kg (up 0.9 kg from last visit). Fundal height 28 cm. Fetal heart rate 148 by Doppler. Urine dip negative for protein and glucose. Fetus in cephalic-variable position on Leopolds, no edema beyond trace at the ankles. One-hour 50 g glucose challenge drawn today; Rh type O positive, antibody screen negative from first trimester.
1) Intrauterine pregnancy at 28 weeks 2 days, G2P1001, progressing normally with reassuring fundal height and fetal heart rate. 2) Gestational diabetes screening in progress. 3) Rh positive, no isoimmunization risk.
Review the one-hour glucose result; if 140 mg/dL or above, order the three-hour glucose tolerance test. Repeat CBC today to check for anemia. Continue prenatal vitamins. Reviewed fetal movement precautions and preterm labor warning signs. Tdap to be given at the next visit. Return in 2 weeks, then move to every-two-week visits. Patient verbalized understanding.
Illustrative example. Not a real patient encounter.
Built for OB/GYN coding and your EMR
Notes capture the history, exam, and decision-making behind an E/M or preventive level, and the operative detail behind a procedure. That is what chart review looks for, and the first thing to slip when you are running behind between visit types.
- 99385 / 99395Preventive visit, new or established, well-woman exam ages 18 to 39
- 99214Established-patient gyn visit, moderate complexity
- 59400Global obstetric care: antepartum, vaginal delivery, and postpartum
- Q0091Screening Pap smear collection and handling for Medicare
- 57454Colposcopy of the cervix with biopsy and endocervical curettage
- 58300Insertion of intrauterine device (IUD)
- Z34.82Encounter for supervision of normal pregnancy, second trimester
- O24.410Gestational diabetes mellitus in pregnancy, diet controlled
- Z01.419Encounter for gynecological exam without abnormal findings
- N92.0Excessive and frequent menstruation with regular cycle
- N95.1Menopausal and female climacteric states
Fits the workflow you already have
Drafts drop into the major EMRs OB/GYN practices run on: Epic (including the OB and Stork prenatal workflows), Oracle Health (Cerner), and athenahealth. You get whatever note type you are working in, a prenatal follow-up, a gyn problem visit, an annual exam, or a procedure report. It writes up the flow-sheet numbers and exam findings you dictate, but it does not read the ultrasound images or measure biometry for you. It records the interpretation you give, and you sign it.
What's Happening in OB/GYN
ACOG Recommends Overhaul of US Prenatal Care Model
ACOG released groundbreaking guidance recommending tailored prenatal care over the traditional 12-14 visit schedule. An initial comprehensive needs assessment should occur before 10 weeks, including medical history and social determinants of health screening.
Individualized prenatal care plans require thorough documentation of complex needs assessments, social determinants, and evolving care plans. AI transcription ensures these comprehensive evaluations are fully captured.
Read moreCMS Establishes First-Ever Maternal Health Standards for Hospitals
CMS announced first-ever maternal health and safety standards for hospitals, setting baselines for organization, staffing, and care delivery in obstetrical units including mandatory QAPI programs and staff training requirements.
New hospital standards require documented compliance with maternal health protocols, staff training records, and quality metrics. Consistent clinical documentation supports these regulatory requirements.
Read moreUS Maternal Mortality Rate Nearly Double Comparable Countries
In 2023, 669 women died of maternal causes at a rate of 18.6 per 100,000 live births, almost twice the rate of comparable economies. Black women face a rate of 44.8 vs. 14.2 for white women.
Addressing maternal mortality requires thorough documentation of risk factors, screening results, and care coordination. AI transcription ensures no critical clinical details are missed during prenatal and postpartum encounters.
Read moreOB/GYN AI scribe questions
Does it get the obstetric terminology and dates right?
Can it handle the switch between OB, gyn, and well-woman visits?
Does it document procedures like colposcopy or IUD placement?
How is patient information protected?
Does it connect to our EMR and prenatal flow sheet?
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