OB/GYN dictation software for prenatal, delivery and GYN notes

An OB/GYN week covers more document types than most specialties: prenatal visits, triage notes, labor progress notes, delivery and cesarean operative notes, postpartum visits, annual exams, colposcopy and LEEP procedure notes, and GYN surgery. Each uses a different slice of vocabulary, from Bishop score to HSIL to salpingo-oophorectomy. Dictation saves the most time in the long ones, the delivery summary and the operative note, where typing at the end of a night shift is slowest.

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Words that general dictation tools get wrong in OB/GYN

Many obstetric terms sound like ordinary words. "Gravida" is easily heard as "gravity", and procedure names break into fragments. The Healthcare dictionary corrects mishearings such as:

• "sea section" to C-section, and "cesarian section" to cesarean section
• "epizio tomy" to episiotomy, "oof orectomy" to oophorectomy and "salpingo ooph erectomy" to salpingo-oophorectomy
• "colposcapee" to colposcopy and "tubal lie gation" to tubal ligation
• "preeclampsa" to preeclampsia and "placenta preeva" to placenta previa
• "Bisshop score" to Bishop score and "polyhydramneeos" to polyhydramnios
• "postpartum hemmorage" to postpartum hemorrhage

On Mac, choosing OB/GYN as your specialty also settles close calls in your favour. When a misheard word sits between two real words, the OB/GYN term wins, so "gravita" is written as gravida rather than gravity.

What the OB/GYN specialty setting does

The specialty picker is in the Mac app under Settings. With OB/GYN selected, recognition is primed with obstetric and gynecologic terms such as gestation, preeclampsia, gestational diabetes, nonstress test, biophysical profile, amniotic fluid, VBAC, Pap smear, LEEP, endometriosis, levonorgestrel and intrauterine device. Every other medical term in the 74,000+ term dictionary is still recognized. Windows has no picker and uses the full dictionary for every note.

Notes you can dictate

Obstetrics

• Prenatal visits: gravida and para, gestational age, fundal height, fetal heart rate, blood pressure, glucose tolerance results.
• Antenatal testing: biophysical profile, amniotic fluid index, Doppler ultrasound findings.
• Labor and delivery: cervical dilation and effacement, Bishop score, induction with oxytocin or misoprostol, magnesium sulfate for preeclampsia, delivery summary, laceration repair.
• Cesarean operative notes: indication, Pfannenstiel incision, low transverse hysterotomy, estimated or quantitative blood loss, closure.
• Postpartum visits, including screening for postpartum depression.

Gynecology

• Annual exams with Pap smear and HPV results.
• Colposcopy and LEEP notes for LSIL or HSIL.
• Endometrial biopsy, hysteroscopy, endometrial ablation and dilation and curettage.
• Operative notes for laparoscopy, hysterectomy, myomectomy, salpingectomy and salpingo-oophorectomy.

Example: dictating a cesarean section operative note

1. Pre and postoperative diagnosis. Press Command+Shift+Space and say: "Gravida 2 para 1 at 39 weeks 2 days, repeat low transverse cesarean section, declined trial of labor after cesarean." Press the hotkey again.
2. Procedure: press Command+Shift+Space and say: "Pfannenstiel incision through the prior scar. Low transverse hysterotomy. Viable female infant delivered from vertex, Apgars 8 and 9. Placenta delivered intact. Uterus closed in two layers." Press the hotkey again.
3. Findings and blood loss: press Command+Shift+Space and say: "Normal tubes and ovaries bilaterally. Quantitative blood loss 750 milliliters. No signs of postpartum hemorrhage. Oxytocin infusion continued." Press the hotkey again.
4. Disposition: press Command+Shift+Space and say: "Mother and infant to recovery in stable condition. Counts correct times two." Press the hotkey again.

Each press of the hotkey ends a dictation. VoicePrivate then transcribes on your computer and pastes the text at the cursor. Nothing shows up while you are still talking.

Into Epic, Cerner, athena and other EHRs

VoicePrivate pastes through your clipboard, puts your previous clipboard contents back, and needs no integration with the EHR. Click the field in Epic, Oracle Health (Cerner), athenahealth, eClinicalWorks, NextGen or ModMed, dictate, and stop. Hospital L&D units often run Epic through Citrix. That works when the Citrix session allows clipboard redirection from your computer, which your IT team controls. The EHR dictation guide has the details per system.

Privacy facts

VoicePrivate processes your speech on the computer it runs on. Audio never leaves that computer and is not sent to a cloud service. With Auto-save transcriptions on, which is the default, each dictation is also kept in the app's Library on that computer. Turn it off in Settings if you want the EHR to hold the only copy.

Price

Healthcare Edition is $297 a year or $34.99 a month for one clinician. There is no free trial. Individual monthly and annual plans include a 30-day money-back guarantee on the first payment. Women's health groups of 2 to 20 clinicians can buy team seats.

OB/GYN dictation FAQ

OB/GYN overlaps with surgical dictation for GYN cases, anesthesiology dictation for labor epidurals, radiology dictation for ultrasound reports and oncology dictation for gynecologic oncology. For a broader overview, read what medical dictation is.