AI-Powered OB/GYN EHR for Prenatal Care and Women’s Health

Althea Smart EHR includes a dedicated prenatal flowsheet that tracks fundal height, fetal heart tones, weight gain, blood pressure, edema, and lab results visit by visit throughout the pregnancy. Each prenatal visit auto-populates prior data, you only document changes. AI Ambient Charting listens during the visit and generates a structured prenatal note in real time, so your documentation is complete before the patient leaves the exam room.

Althea Smart EHR tracks the complete global OB episode from the first prenatal visit through delivery and the postpartum visit. The AI Billing Assistant confirms the correct global package code, CPT 59400 (vaginal delivery), 59510 (cesarean delivery), 59610 (VBAC), or 59618 (attempted VBAC/C-section), at claim submission. When care is transferred, Althea Smart EHR automatically switches to antepartum-only codes (59425 or 59426) based on documented visit count.

Yes, Althea Smart EHR includes a real-time L&D patient dashboard showing all active laboring patients, admission time, gestational age, dilation, contractions, EFM status, and delivery plan, managed directly from your iPhone or iPad. AI Ambient Charting listens at bedside and generates progress and delivery notes in real time, so your L&D documentation is done before you leave the floor.

Althea Smart EHR includes pre-built operative note templates for cesarean sections, hysterectomy, myomectomy, laparoscopy, LEEP, colposcopy, and in-office procedures. AI Ambient Charting listens during the procedure and generates the structured operative report in real time, so your surgical documentation is complete before you leave the OR or procedure suite.

Althea Smart EHR surfaces cervical screening and mammography care gap alerts at every annual GYN visit, prompting Pap smear recall, HPV co-test scheduling, and mammography referrals when patients are overdue. Abnormal Pap and colposcopy results are tracked longitudinally within the patient chart, with automated follow-up reminders ensuring no cervical abnormality goes unaddressed in your panel.

Althea Smart EHR includes gestational age-specific protocol alerts, first trimester lab panel, NIPT timing, anatomy survey scheduling, GDM screening at 24–28 weeks, GBS culture at 36 weeks, Tdap administration, and Rhogam for Rh-negative patients. Each alert surfaces automatically at the appropriate prenatal visit so no screening is missed and documentation is always complete.

MD Synergy eliminates all three disruption sources: free data migration before go-live, 2-hour training required for Althea Smart EHR for the provider, and 100% patient go-live on Day 1.

Althea Smart EHR’s AI Billing Assistant surfaces the correct CPT code for every gynecologic procedure, LEEP (57461), colposcopy (57420/57421), endometrial biopsy (58100), IUD insertion (58300), hysteroscopy, laparoscopy, and surgical procedures, with modifier guidance for bilateral procedures, staged surgeries, and assistant surgeon billing. Under-coded procedures and missing documentation are flagged before claim submission.

Annual GYN visits billed as preventive services require different coding than problem-focused encounters. Althea Smart EHR’s AI Billing Assistant correctly identifies visit type at every encounter, ensuring preventive visits (99385–99387 / 99395–99397) and problem-focused visits (99202–99215) are coded separately when both are documented on the same date, applying modifier -25 appropriately to prevent claim denials.

Althea Smart EHR’s AI Ambient Charting listens during prenatal visits, gynecologic exams, and in-office procedures, identifies the encounter type, new OB visit, prenatal return, annual GYN, colposcopy, or procedure note, and generates the appropriate structured note in real time. Most notes are complete before the patient gets dressed.

Althea Smart EHR automatically schedules postpartum follow-up appointments at 4–8 weeks after delivery, sends automated appointment reminders, and surfaces the Edinburgh Postnatal Depression Scale (EPDS) screening within the postpartum visit template. Postpartum visit documentation closes the global OB billing episode, ensuring the complete 59400 or 59510 package is captured.

Althea Smart EHR includes a built-in MIPS Dashboard, women’s health HEDIS measure tracking, prenatal and postpartum care, cervical cancer screening, breast cancer screening, chlamydia screening, a panel-wide Quality Dashboard, and QRDA reporting for compliant CMS quality measure submissions, directly impacting reimbursement in value-based contracts.

Six criteria that matter for OB/GYN: (1) AI ambient charting for prenatal visits and operative notes, (2) L&D board and obstetric hospital workflows, (3) Global OB billing automation and antepartum unbundling, (4) Gynecologic procedure code capture with modifier guidance, (5) Women’s health preventive care gap tracking and HEDIS measures, (6) No setup fees and flexible contract terms. Althea Smart EHR meets all six, rated 5.0 ★ on Capterra.

OB/GYN physicians document across the full care spectrum, prenatal visits, deliveries, operative reports, and GYN procedures, often including middle-of-the-night documentation after deliveries. Practices using Althea Smart EHR reported cutting their charting time in half, with most notes completed before the patient leaves, giving physicians back hours every day and eliminating after-hours catch-up documentation.