|
Referring Dr Name when using familiar
|
|
|
Date
|
|
|
Patient Name - Auto
|
|
|
Patient Birth Date
|
|
|
Familiar
|
|
|
Salutation
• • •
|
PA / PA-C / NP / ARNP
• • •
|
|
Intro - Reason for Fetal
|
Enter EDD
|
|
Enter Weeks gestation
|
Enter Days Gestation
|
|
Enter pregnancy number
|
Enter number living children
|
|
Other Information
|
|
|
Medications other than prenatal
|
Medications - Other info
|
|
Complications
|
Listing of Complications
|
|
Family history of CHD
|
Listing of Family History Issues
|
|
Other Information
|
|
|
Results - Dictate
|
Discussed lesions cannot R/O
|
|
Plans - Dictate
|
Language line - # of minutes
|
|
Follow up?
|
<--IF YES follow up time.
|
|
Closing - Sincerely
|
|
|
CC
• • •
|
CC - Type
|
|
Enclosure: Fetal Echocardiogram
|
|
