Obstetrician & Gynaecologist Template

New Prenatal Consult

A professional Obstetrician & Gynaecologist template for healthcare professionals.

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Specialty

Obstetrician & Gynaecologist

Used

256 times

Type

Note

Last edited

9/27/2024

Created by

Unknown Author

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About this template

The New Prenatal Consult template is designed for obstetricians and gynecologists to document initial prenatal visits. This comprehensive template includes sections for current pregnancy details, past obstetrical and medical history, social history, physical examination, prenatal investigations, ultrasounds, vaccinations, and a detailed plan. It is ideal for capturing high-risk pregnancy factors and planning ongoing care. This template ensures thorough documentation, facilitating effective communication between healthcare providers. It is optimized for use with AI medical scribe Heidi, enhancing efficiency and accuracy in prenatal care documentation.

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Thank you for your referral of Jane Doe, a 28-year-old Gravida 2, Para 1 at 20 weeks gestation. Her EDC is March 15, 2024, by first trimester ultrasound, done at 12 gestational weeks. She was referred because of elevated maternal BMI and gestational diabetes. This Pregnancy: - Elevated maternal BMI, gestational diabetes Past Obstetrical History: - Previous pregnancy complicated by preeclampsia Medical History: - Hypertension - Prenatal vitamins - No known drug allergies - Appendectomy in 2015 - History of HPV, last pap normal in 2022 Social History: - Non-smoker, occasional alcohol use - Software engineer - Supported by partner and family - Lives in urban community Physical Examination: - Blood pressure: 130/85 mmHg, Heart rate: 78 bpm, Weight: 180 lbs, Height: 5'6", BMI: 29 - Symphysis fundal height: 20 cm - Cephalic fetal presentation - Fetal heart rate: 150 bpm Prenatal Investigations: - Blood type: O+, Rh factor: positive, Hepatitis B: negative, Hepatitis C: negative, HIV: negative, Syphilis: negative, Rubella: immune, Varicella: immune, GBS: pending, complete blood count: normal - Maternal serum screen: low risk - Urine tests: normal - EDS score on Edinburgh PPDS: 5 Ultrasounds: - Ultrasound on October 1, 2023, at 20 weeks gestation, findings: cephalic presentation, anterior placenta, normal anatomy, estimated fetal weight in 50th percentile, normal amniotic fluid, BPP score: 8/8 Vaccination: - We discussed the vaccines recommended in pregnancy, including Tdap, influenza, and Covid. Patient is interested and will receive them at the next visit. Impression: - High-risk pregnancy due to gestational diabetes and elevated maternal BMI Plan: - I will assume this patient's care with shared care from the referring physician. - We discussed the Obstetrical call system and reviewed that we work in a teaching hospital and learners including medical students and residents work with our team and will most likely be involved in her care. - Follow-up appointment in 4 weeks - Recommended lifestyle modifications: balanced diet and regular exercise - Continue prenatal vitamins - Referral to a nutritionist for gestational diabetes management Thank you again for involving me in her care.