Ob-Gyn Risk Alliance
Sample Ob Risk Assessment Checklist
[Practice Name]
This form should be completed for all patients.
/ /
Patient Name (please print) Patient DOB
EDD: / / Pre-Pregnancy Weight: Current Weight: Weight Gain:
|Risk Factors (check all that apply) |Plan |Patient Discussion |
|Shoulder Dystocia |
|Date identified: / / |Serial U/S |Discussed risk factors with pt |
|Maternal weight | |Date: / / |
|Maternal height |Last U/S completed | |
|Maternal BMI > 35 |Weeks gestation: |Conducted delivery |
|Weight gained > 50 lbs. | |consent discussion |
|Diabetes |Pelvimetry performed |Date: / / |
|Gestational diabetes |Date: / / | |
|Estimated fetal wt > 4,500 grams w/ diabetes | |[Insert other] |
|Estimated fetal wt > 5,000 grams w/o diabetes |Biophysical profile | |
|Fundal height > 42 cm |Date: / / |[Insert other] |
|Gestational age | | |
|Prior hx of vaginal delivery |OB unit alerted, if applicable | |
|Prior hx of shoulder dystocia |Date: / / | |
|[Insert other risk factor] | | |
|[Insert other risk factor] |[Insert other, e.g., dx test] | |
| | | |
| |[Insert other] | |
|Postpartum Hemorrhage (PPH) |
|Date identified: / / |Anticardiolipin anticoagulant |Discussed risk factors with pt |
|Previous hx PPH |Weeks gestation: |Date: / / |
|Previous uterine atony | | |
|Abnormal placentation |Anti-B2-glycoprotein 1 IgG |Conducted delivery |
|Severe preeclampsia or eclampsia |IgM antibodies |consent discussion |
|Obesity |Weeks gestation: |Date: / / |
|High parity | | |
|Multiple fetuses |CBC with platelet count |[Insert other] |
|Hydramnios |Weeks gestation: | |
|Chorioamnionitis | |[Insert other] |
|Maternal coagulopathy |PT/PTT/INR | |
|Anticoagulant therapy |Weeks gestation: | |
|Ethnicity: Native American, Hispanic, Asian | | |
|[Insert other risk factor] |Complete metabolic profile | |
|[Insert other risk factor] |Weeks gestation: | |
| | | |
| |OB unit alerted, if applicable | |
| |Date: / / | |
| | | |
| |[Insert other, e.g., dx test] | |
| | | |
| |[Insert other] | |
/ /
Signature Date
Supplemental Sample Ob Risk Assessment Checklist
[Practice Name]
This form should be completed as necessary.
/ /
Patient Name (please print) Patient DOB
EDD: / / Pre-Pregnancy Weight: Current Weight: Weight Gain:
|Risk Factors (check all that apply) |Plan |Patient Discussion |
|Preeclampsia/Eclampsia |
|Date identified: / / |[Insert] |Discussed risk factors with pt |
| | |Date: / / |
| |[Insert] | |
| | |[Insert other] |
|Labor Induction/Augmentation |
|Date identified: / / |Labor induced/augmented |Discussed risk factors with pt |
|Medical indicators documented |Weeks gestation*: |Date: / / |
|[Insert other risk factor] |*If elective, not less than 39 weeks | |
|[Insert other risk factor] | |Patient signed consent form |
| |Bishop score present |Date: / / |
| | | |
| |Biophysical profile performed |[Insert other] |
| |Weeks gestation: | |
| | | |
| |EDC confirmed by U/S | |
| | | |
| |Fetal non-stress testing performed | |
| |Weeks gestation: | |
| | | |
| |Contraction stress test performed | |
| |Weeks gestation: | |
| | | |
| |[Insert] | |
| | | |
| |[Insert] | |
|[Other] |
|Date identified: / / |[Insert] |[Insert] |
| |[Insert] |[Insert] |
/ /
Signature Date
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.