Maternity Care Package (Page 2 of 4) in pdf

PHILHEALTH

MATERNITY CARE

PACKAGE

CLAIM FORM 4A

April 2003

NOTE: THIS FORM TOGETHER WITH CLAIM FORM 4 SHOULD BE FILED WITH PHILHEALTH WITHIN 60 CALENDAR DAYS FROM DATE OF DISCHARGE.

Name of Physician/Midwife:

Name of Facility:

Address of Facility:

Name of Patient:

PART I - PRENATAL

INITIAL PRENATAL CONSULTATION (date: ___/___/___)

A. Clinical History and Physical Examination

1. Vital signs are normal

2. Menstrual History

LMP : ____________

Menarche: ____________

4. Obstetric History

G______ P______ ( ______ ,______ ,______ ,______ )

5. Ascertain 1st Pregnancy was Low-Risk

6. Obstetric risk factors

a. Multiple pregnancy

f. History of stillbirth

b. Ovarian cyst

g. History of pre-eclampsia

c. Myoma uteri

h. History of eclampsia

d. Placenta previa

i. Premature contraction

e. History of 3 miscarriages

Medical/Surgical Risk Factors

a. Hypertension

g. Epilepsy

b. heart disease

h. Renal disease

c. Diabetes

I. Bleeding disorders

d. Thyroid disorders

j. History of previous cesarean section

e. Obesity

k. History of uterine myomectomy

f. Moderate to severe asthma

8. Determine pertinent abdominal examinations

a. Abdomen

normoactive bowel sound

fundic ht= _______________

Leopold's Maneuver L1: ________ L3: _________

non-tender

estimated fetal wt: _________

L2: ________ L4: _________

active fetal movements

FHT= __________

presentation: __________________________

b. Speculum Exam

c. Internal Exam

parous vagina

uterus enlarged to AOG

cervix smooth, closed

adnexal masses

9. Give complete diagnosis: _________________________________________________________________________

B. Write Delivery Plan indicating:

1. Orientation to LRMC Package/Availment of Benefits

3. Expected date and venue of delivery

2. Schedule of prenatal examinations

Date: ___/___/___

Place: ___________________

FOLLOW-UP PRENATAL CONSULTATION (date: ___/___/___)

Visit No.

2nd

3rd

4th

5th

6th

7th

8th

9th

10th

11th

12th

Date of visit

A. Determine AOG in weeks

B. Obtain vital signs

a. Wt

b. HR

c. RR

d. BP

e. T

PART II - NORMAL BIRTH (date:__/__/__)

DONE

A. Perform complete Physical Examination (VS)

1. Determine AOG

AOG: ___________

LMP: ___________

2. Obtain Vital Signs

HR: _____

RR: _____

BP: _____ T: ____

3. Perform pertinent physical examination

a. HEENT

b. Heart/Lungs

c. Skin/Extremities

(+)

(-)

(+)

(-)

(+)

(-)

anicteric sclerae

clear breath sounds

full pulses

(+)

(-)

(+)

(-)

(+)

(-)

pink palpebral conjunctiva

sinus rhythm

bipedal edema

REMARKS _______________

Maternity Care Package Page 2

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