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Care Team
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Primary Maternal Provider/Group:
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Care Coordinator:
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Home Visitor:
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PCP:
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MFM:
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Infant Medical Provider:
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Consultant:
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Lactation Support:
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Consultant:
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Postpartum Visits
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Early Visit (Indication)
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At:
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Please select
• • •
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Other:
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Comprehensive Visit
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At:
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Reproductive Life Plan
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Number Of Children Desired:
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Timing Of Next Pregnancy:
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Contraceptive Plan
• • •
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Other
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Immediate Postpartum LARC?
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Infant Feeding Plan
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If, Exclusive Breastfeeding for how many months
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Community Resources
• • •
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Pregnancy Complications
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Complication
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GDM
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Preeclampsia
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GHTN
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Other:
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Follow-Up Scheduled
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Glucose Screen:
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BP Check
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Result
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MG/DL (Fasting)
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MG/DL (Post 75 G Load)
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MM HG
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Mental Health
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Risk For Postpartum Depression/Anxiety
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Screening (Should Be Performed At Least Once During Perinatal Period)
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Date:
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Result
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Postpartum Problems
• • •
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Referrals/Interventions:
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Chronic Health Conditions
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Problem
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Plan
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Problem
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Plan
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Problem
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Plan
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Problem
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Plan
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ID#:
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EDD
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Discharge Date:
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Delivery At
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Vaginal
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Svd
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Vacuum
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Forceps
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Episiotomy
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Lacerations
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Tolac
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Cesarean
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Discharge Date:
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Repeat For:
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Uterine Incision
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Low Transverse
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Low Vertical
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Classical
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Labor
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Anesthesia
• • •
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Other
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Postpartum Contraception
• • •
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Other
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Delivered By:
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Postpartum Information
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Complications
• • •
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Other
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Neonatal Information
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Name Of Baby:
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Sex
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Circumcision
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Birth Weight:
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Disposition
• • •
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Other
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Complications/Anomalies
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Newborn Care Provider
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Seen By Newborn Care Provider Before Discharge
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Received Hepatitis B Birth Dose Prior to Hospital Discharge
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Maternal Information
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Maternal Age:
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Gravity And Parity
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Regarding Smoking, Chewing, Using A Nicotine Delivery System (ENDS)/Vaping
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HGB/HCT Level:
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Medications:
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HIV Status* Known
• • •
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Feeding Method
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Diagnostic Studies Pending:
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Secondary Diagnosis/Preexisting Conditions
• • •
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Other
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Immunizations Given
• • •
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Tdap Or TD
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Influenza
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Other
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Infant Status:
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If Neonatal Death, Bereavement Counseling
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Follow-Up Appt:
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Date:
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Location:
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Other:
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Interim Contacts Or Hospitalizations
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Date
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Comment
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Date
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Comment
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Date
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Comment
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Date
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Comment
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Date
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Comment
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Postpartum Visit
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Feeding Method:
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Allergies
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Contraception Method
• • •
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Other
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Immunization Update:
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Medications/Contraception:
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Postpartum Depression Screening:
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Intimate Partner Violence Screening:
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Discuss Tobacco (Smoked, Chewed, ENDS, Vaped) Relapse Prevention Techniques:
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Dispensed
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Infant Health:
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Interim History:
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Follow-Up Lab Studies Ordered
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Postpartum HCB/HCT
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Comments
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Postpartum Glucose Screening If Patient Had Gestational Diabetes
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Comments
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Other Studies Requested
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Comments
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Interval Care Recommendations
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For General Health Promotion
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Plans For Future Pregnancies
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For Reproductive Health Promotion
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Repeat Glucose Screening Needed?
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If Yes, Has Patient Been Counseled?
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Date Of Repeat Testing
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Return Visit
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Referrals
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Examined By
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Physical Examination
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Breasts
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Comments
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Abdomen
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Comments
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External Genitalia
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Comments
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Vagina
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Comments
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Cervix
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Comments
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Uterus
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Comments
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Adnexa
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Comments
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Rectal–Vagina
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Comments
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Pap Test
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If No, Due
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Comments
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