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OB PROB LIST
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OB PROBLEM 1
• • •
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F/U
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OB PROBLEM 2
• • •
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F/U
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OB PROBLEM 3
• • •
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F/U
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OB PROBLEM 4
• • •
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F/U
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OB PROBLEM 5
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F/U
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ADDITIONAL OB PROBLEMS
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F/U
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INFO
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PRIMARY OB
• • •
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MEDICAL ALLERGIES & REACTIONS
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G AND P STATUS
• • •
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EDC - MONTH, DAY, YEAR
• • •
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EDC BY:
• • •
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PMHX & PSHX
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OTHER CHILDREN'S NAMES:
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FATHER'S NAME
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OB Hx
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PR # 1: YR, HOSP, WKS, HRS, DEL TYPE, SEX, WT
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PR # 2: YR, HOSP, WKS, HRS, DEL TYPE, SEX, WT
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PR # 3: YR, HOSP, WKS, HRS, DEL TYPE, SEX, WT
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PR # 4: YR, HOSP, WKS, HRS, DEL TYPE, SEX, WT
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OTHER PREGNANCIES & COMMENTS
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GENERAL AND PELVIC EXAM
• • •
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ADDITIONAL COMMENTS RE: EXAM
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OB LABS
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GBS POS (URINE OR SWAB)?
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ABO RH
• • •
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Hgb OR Hct - RESULTS AND DATE
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MCV < 80?
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PLAT # <150K?
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HBsAg REACTIVE?
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RPR POS?
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HIV POSITIVE?
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RUBELLA NON-IMMUNE?
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CF POS?
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PARVOVIRUS NON-IMMUNE?
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1 Hr GLUCOLA >130?
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CHICKENPOX NON-IMMUNE?
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ASCHKENAZI JEWISH SCREEN POSITIVE?
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URINE GC/CHLAMYDIA POSITIVE?
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COUNSYL TEST RESULT NOT NORMAL?
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PAP NOT NORMAL?
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1ST TRIM SCREEN NOT NORMAL ?
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FETAL CELL FREE DNA TEST NOT NORMAL?
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2ND TRIM US NOT NORMAL ?
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2ND TRIMESTER SCREEN NOT NORMAL?
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COMMENTS ON ANY OF THE ABOVE LABS
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TSH & FT4 - RESULTS AND DATE
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Tdap GIVEN?
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FLU SHOT GIVEN?
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RHOGAM GIVEN?
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COMMENTS RE RHOGAM
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PRENATAL VISITS
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ROB #1 DATE
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GESTATIONAL AGE : WEEKS AND DAYS
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HIGH RISK OB VISIT?
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SBP
• • •
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DBP
• • •
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WEIGHT
• • •
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FH
• • •
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POSITION
• • •
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FM
• • •
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FETAL HEART TONES
• • •
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URINE
• • •
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ADDITIONAL COMMENTS RE OB VITALS
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MANUAL CERVICAL EXAM
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NST/AFI DONE AND BOTH OK?
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AFI FINDINGS
• • •
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NST
• • •
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ALL U/S AND NST FINDINGS
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ASSESSMENT & PLAN
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VISIT CPT
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VISIT ICD-10
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FOLLOW UP VISIT
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ADDITIONAL VISIT CPT/ICD-10
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ROB #2 DATE
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GESTATIONAL AGE : WEEKS AND DAYS
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HIGH RISK OB VISIT?
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SBP
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DBP
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WEIGHT
• • •
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FH
• • •
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POSITION
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FM
• • •
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FETAL HEART TONES
• • •
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URINE
• • •
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ADDITIONAL COMMENTS RE OB VITALS
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MANUAL CERVICAL EXAM
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NST/AFI DONE AND BOTH OK?
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AFI FINDINGS
• • •
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NST
• • •
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ALL U/S AND NST FINDINGS
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ASSESSMENT & PLAN
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VISIT CPT
• • •
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VISIT ICD-10
• • •
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FOLLOW UP VISIT
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ADDITIONAL VISIT CPT/ICD-10
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ROB #3 DATE
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GESTATIONAL AGE : WEEKS AND DAYS
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HIGH RISK OB VISIT?
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SBP
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DBP
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WEIGHT
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FH
• • •
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POSITION
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FM
• • •
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FETAL HEART TONES
• • •
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URINE
• • •
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ADDITIONAL COMMENTS RE OB VITALS
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MANUAL CERVICAL EXAM
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NST/AFI DONE AND BOTH OK?
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AFI FINDINGS
• • •
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NST
• • •
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ALL U/S AND NST FINDINGS
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ASSESSMENT & PLAN
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VISIT CPT
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VISIT ICD-10
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FOLLOW UP VISIT
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ADDITIONAL VISIT CPT/ICD-10
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ROB #4 DATE
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GESTATIONAL AGE : WEEKS AND DAYS
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HIGH RISK OB VISIT?
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SBP
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DBP
• • •
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WEIGHT
• • •
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FH
• • •
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POSITION
• • •
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FM
• • •
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FETAL HEART TONES
• • •
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URINE
• • •
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ADDITIONAL COMMENTS RE OB VITALS
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MANUAL CERVICAL EXAM
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NST/AFI DONE AND BOTH OK?
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AFI FINDINGS
• • •
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NST
• • •
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ALL U/S AND NST FINDINGS
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ASSESSMENT & PLAN
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VISIT CPT
• • •
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VISIT ICD-10
• • •
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FOLLOW UP VISIT
• • •
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ADDITIONAL VISIT CPT/ICD-10
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ROB #5 DATE
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GESTATIONAL AGE : WEEKS AND DAYS
• • •
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HIGH RISK OB VISIT?
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SBP
• • •
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DBP
• • •
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WEIGHT
• • •
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FH
• • •
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POSITION
• • •
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FM
• • •
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FETAL HEART TONES
• • •
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URINE
• • •
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ADDITIONAL COMMENTS RE OB VITALS
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MANUAL CERVICAL EXAM
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NST/AFI DONE AND BOTH OK?
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AFI FINDINGS
• • •
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NST
• • •
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ALL U/S AND NST FINDINGS
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ASSESSMENT & PLAN
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VISIT CPT
• • •
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VISIT ICD-10
• • •
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FOLLOW UP VISIT
• • •
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ADDITIONAL VISIT CPT/ICD-10
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ROB #6 DATE
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GESTATIONAL AGE : WEEKS AND DAYS
• • •
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HIGH RISK OB VISIT?
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SBP
• • •
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DBP
• • •
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WEIGHT
• • •
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FH
• • •
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POSITION
• • •
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FM
• • •
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FETAL HEART TONES
• • •
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URINE
• • •
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ADDITIONAL COMMENTS RE OB VITALS
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MANUAL CERVICAL EXAM
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NST/AFI DONE AND BOTH OK?
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AFI FINDINGS
• • •
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NST
• • •
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ALL U/S AND NST FINDINGS
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ASSESSMENT & PLAN
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VISIT CPT
• • •
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VISIT ICD-10
• • •
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FOLLOW UP VISIT
• • •
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ADDITIONAL VISIT CPT/ICD-10
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ROB #7 DATE
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GESTATIONAL AGE : WEEKS AND DAYS
• • •
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HIGH RISK OB VISIT?
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SBP
• • •
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DBP
• • •
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WEIGHT
• • •
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FH
• • •
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POSITION
• • •
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FM
• • •
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FETAL HEART TONES
• • •
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URINE
• • •
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ADDITIONAL COMMENTS RE OB VITALS
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MANUAL CERVICAL EXAM
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NST/AFI DONE AND BOTH OK?
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AFI FINDINGS
• • •
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NST
• • •
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ALL U/S AND NST FINDINGS
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ASSESSMENT & PLAN
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VISIT CPT
• • •
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VISIT ICD-10
• • •
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FOLLOW UP VISIT
• • •
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ADDITIONAL VISIT CPT/ICD-10
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ROB #8 DATE
• • •
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GESTATIONAL AGE : WEEKS AND DAYS
• • •
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HIGH RISK OB VISIT?
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SBP
• • •
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DBP
• • •
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WEIGHT
• • •
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FH
• • •
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POSITION
• • •
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FM
• • •
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FETAL HEART TONES
• • •
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URINE
• • •
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ADDITIONAL COMMENTS RE OB VITALS
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MANUAL CERVICAL EXAM
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NST/AFI DONE AND BOTH OK?
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AFI FINDINGS
• • •
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NST
• • •
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ALL U/S AND NST FINDINGS
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ASSESSMENT & PLAN
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VISIT CPT
• • •
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VISIT ICD-10
• • •
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FOLLOW UP VISIT
• • •
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ADDITIONAL VISIT CPT/ICD-10
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ROB #9 DATE
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GESTATIONAL AGE : WEEKS AND DAYS
• • •
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HIGH RISK OB VISIT?
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SBP
• • •
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DBP
• • •
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WEIGHT
• • •
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FH
• • •
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POSITION
• • •
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FM
• • •
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FETAL HEART TONES
• • •
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URINE
• • •
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ADDITIONAL COMMENTS RE OB VITALS
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MANUAL CERVICAL EXAM
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NST/AFI DONE AND BOTH OK?
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AFI FINDINGS
• • •
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NST
• • •
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ALL U/S AND NST FINDINGS
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ASSESSMENT & PLAN
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VISIT CPT
• • •
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VISIT ICD-10
• • •
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FOLLOW UP VISIT
• • •
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ADDITIONAL VISIT CPT/ICD-10
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ROB #10 DATE
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GESTATIONAL AGE : WEEKS AND DAYS
• • •
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HIGH RISK OB VISIT?
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SBP
• • •
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DBP
• • •
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WEIGHT
• • •
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FH
• • •
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POSITION
• • •
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FM
• • •
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FETAL HEART TONES
• • •
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URINE
• • •
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ADDITIONAL COMMENTS RE OB VITALS
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MANUAL CERVICAL EXAM
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NST/AFI DONE AND BOTH OK?
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AFI FINDINGS
• • •
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NST
• • •
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ALL U/S AND NST FINDINGS
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ASSESSMENT & PLAN
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VISIT CPT
• • •
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VISIT ICD-10
• • •
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FOLLOW UP VISIT
• • •
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ADDITIONAL VISIT CPT/ICD-10
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ROB #11 DATE
• • •
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GESTATIONAL AGE : WEEKS AND DAYS
• • •
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HIGH RISK OB VISIT?
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SBP
• • •
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DBP
• • •
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WEIGHT
• • •
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FH
• • •
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POSITION
• • •
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FM
• • •
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FETAL HEART TONES
• • •
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URINE
• • •
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ADDITIONAL COMMENTS RE OB VITALS
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MANUAL CERVICAL EXAM
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NST/AFI DONE AND BOTH OK?
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AFI FINDINGS
• • •
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NST
• • •
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ALL U/S AND NST FINDINGS
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ASSESSMENT & PLAN
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VISIT CPT
• • •
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VISIT ICD-10
• • •
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FOLLOW UP VISIT
• • •
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ADDITIONAL VISIT CPT/ICD-10
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ROB #12 DATE
• • •
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GESTATIONAL AGE : WEEKS AND DAYS
• • •
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HIGH RISK OB VISIT?
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SBP
• • •
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DBP
• • •
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WEIGHT
• • •
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FH
• • •
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POSITION
• • •
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FM
• • •
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FETAL HEART TONES
• • •
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URINE
• • •
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ADDITIONAL COMMENTS RE OB VITALS
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MANUAL CERVICAL EXAM
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NST/AFI DONE AND BOTH OK?
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AFI FINDINGS
• • •
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NST
• • •
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ALL U/S AND NST FINDINGS
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ASSESSMENT & PLAN
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VISIT CPT
• • •
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VISIT ICD-10
• • •
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FOLLOW UP VISIT
• • •
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ADDITIONAL VISIT CPT/ICD-10
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ROB #13 DATE
• • •
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GESTATIONAL AGE : WEEKS AND DAYS
• • •
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HIGH RISK OB VISIT?
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SBP
• • •
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DBP
• • •
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WEIGHT
• • •
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FH
• • •
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POSITION
• • •
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FM
• • •
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FETAL HEART TONES
• • •
|
URINE
• • •
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ADDITIONAL COMMENTS RE OB VITALS
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MANUAL CERVICAL EXAM
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NST/AFI DONE AND BOTH OK?
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AFI FINDINGS
• • •
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NST
• • •
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ALL U/S AND NST FINDINGS
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ASSESSMENT & PLAN
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VISIT CPT
• • •
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VISIT ICD-10
• • •
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FOLLOW UP VISIT
• • •
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ADDITIONAL VISIT CPT/ICD-10
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ROB #14 DATE
• • •
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GESTATIONAL AGE : WEEKS AND DAYS
• • •
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HIGH RISK OB VISIT?
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SBP
• • •
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DBP
• • •
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WEIGHT
• • •
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FH
• • •
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|
POSITION
• • •
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FM
• • •
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FETAL HEART TONES
• • •
|
URINE
• • •
|
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ADDITIONAL COMMENTS RE OB VITALS
|
MANUAL CERVICAL EXAM
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NST/AFI DONE AND BOTH OK?
|
AFI FINDINGS
• • •
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NST
• • •
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ALL U/S AND NST FINDINGS
|
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ASSESSMENT & PLAN
|
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VISIT CPT
• • •
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VISIT ICD-10
• • •
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FOLLOW UP VISIT
• • •
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ADDITIONAL VISIT CPT/ICD-10
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ROB #15 DATE
• • •
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GESTATIONAL AGE : WEEKS AND DAYS
• • •
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HIGH RISK OB VISIT?
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SBP
• • •
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DBP
• • •
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|
WEIGHT
• • •
|
FH
• • •
|
|
POSITION
• • •
|
FM
• • •
|
|
FETAL HEART TONES
• • •
|
URINE
• • •
|
|
ADDITIONAL COMMENTS RE OB VITALS
|
MANUAL CERVICAL EXAM
|
|
NST/AFI DONE AND BOTH OK?
|
AFI FINDINGS
• • •
|
|
NST
• • •
|
ALL U/S AND NST FINDINGS
|
|
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ASSESSMENT & PLAN
|
VISIT ICD-10
• • •
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VISIT CPT
• • •
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ADDITIONAL VISIT CPT/ICD-10
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FOLLOW UP VISIT
• • •
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ROB #16 DATE
• • •
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GESTATIONAL AGE : WEEKS AND DAYS
• • •
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HIGH RISK OB VISIT?
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SBP
• • •
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DBP
• • •
|
|
WEIGHT
• • •
|
FH
• • •
|
|
POSITION
• • •
|
FM
• • •
|
|
FETAL HEART TONES
• • •
|
URINE
• • •
|
|
ADDITIONAL COMMENTS RE OB VITALS
|
MANUAL CERVICAL EXAM
|
|
NST/AFI DONE AND BOTH OK?
|
AFI FINDINGS
• • •
|
|
NST
• • •
|
ALL U/S AND NST FINDINGS
|
|
|
|
|
ASSESSMENT & PLAN
|
|
|
VISIT CPT
• • •
|
VISIT ICD-10
• • •
|
|
FOLLOW UP VISIT
• • •
|
ADDITIONAL VISIT CPT/ICD-10
|
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|
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ROB #17 DATE
• • •
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GESTATIONAL AGE : WEEKS AND DAYS
• • •
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|
|
HIGH RISK OB VISIT?
|
|
SBP
• • •
|
DBP
• • •
|
|
WEIGHT
• • •
|
FH
• • •
|
|
POSITION
• • •
|
FM
• • •
|
|
FETAL HEART TONES
• • •
|
URINE
• • •
|
|
ADDITIONAL COMMENTS RE OB VITALS
|
MANUAL CERVICAL EXAM
|
|
NST/AFI DONE AND BOTH OK?
|
AFI FINDINGS
• • •
|
|
NST
• • •
|
ALL U/S AND NST FINDINGS
|
|
|
|
|
ASSESSMENT & PLAN
|
|
|
VISIT CPT
• • •
|
VISIT ICD-10
• • •
|
|
FOLLOW UP VISIT
• • •
|
ADDITIONAL VISIT CPT/ICD-10
|
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|
|
|
ROB #18 DATE
• • •
|
GESTATIONAL AGE : WEEKS AND DAYS
• • •
|
|
|
HIGH RISK OB VISIT?
|
|
SBP
• • •
|
DBP
• • •
|
|
WEIGHT
• • •
|
FH
• • •
|
|
POSITION
• • •
|
FM
• • •
|
|
FETAL HEART TONES
• • •
|
URINE
• • •
|
|
ADDITIONAL COMMENTS RE OB VITALS
|
MANUAL CERVICAL EXAM
|
|
NST/AFI DONE AND BOTH OK?
|
AFI FINDINGS
• • •
|
|
NST
• • •
|
ALL U/S AND NST FINDINGS
|
|
|
|
|
ASSESSMENT & PLAN
|
|
|
VISIT CPT
• • •
|
VISIT ICD-10
• • •
|
|
FOLLOW UP VISIT
• • •
|
ADDITIONAL VISIT CPT/ICD-10
|
