Pre-natal Care Chart Review



Sparrow/MSU FMRP Prenatal Chart Review FormPatient Name: ______________________ MRN __________________________448818053340HIGH RISK CONDITIONS:1)2)3)4)5)00HIGH RISK CONDITIONS:1)2)3)4)5)Initial Visit/First Trimester (0-12 weeks) Review date_______________________ GA at Review Date _______________G____P____EDD_____________ based on __________________________Primary Resident/Attending___________________________________Blood type: _____ Antibody screen: _______________Rh negative status documented in problem list (if applicable)Hemoglobin□ PlateletsRubella Immune□ Syphilis AntibodyGC/Chlamydia□ Hep B sAgHIV□ Urine CulturePap Result: _________________________Early 1hr Gest DM Screen: ________________Varicella (Hx of disease, 2 vaccines, or titer)Trisomy Screen _______________________________Other Genetic Screening: CF, Sickle Cell, etc.Substance use screen – results addressedWeight/BMI noted and addressed on problem listFlu vaccineOB history collected and entered in EPICClear & complete problem list/OB OverviewNotes/recommendations: Second Trimester (13-28 weeks)Review Date_______________________ GA at Review Date _______________Anatomy US: Results: _________________________ ______________________________28 week labs (CBC, Syphilis Ab, HIV)_____Gest DM Screen (24 to 28 weeks): ___________________Ab screen and Rhogam if indicated (~28 weeks)Drug Screen if indicatedFlu vaccineBreastfeeding discussed, documented in OB OverviewASA for pre-eclampsia prophylaxis if indicated (ideally prior to 16 weeks)MFM referral for hx of Preterm Birth if indicated (16-20 weeks)OB Consult if indicated for TOLAC, Obesity, Hx Preterm Birth, etc.Clear & complete problem list/OB OverviewNotes/recommendations: Third Trimester ( > 28 weeks)Review Date_______________________ GA at Review Date _______________Tdap given (27 to 36 weeks)Flu vaccineGBS Screen (35 to 37 weeks)Presentation by Leopold’s Documented (36 weeks +)Repeat STI screening if high riskClear & complete problem list/OB OverviewFamily planning choice documentedBaby’s doctor documentedLabor Plan documentedOB Consult for PPTL etc.Notes/recommendations: ................
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