Maternity Care Package Page 4

PHILHEALTH

MATERNITY CARE

PACKAGE

CLAIM FORM 4B

April 2003

NOTE: THIS FORM TOGETHER WITH CLAIM FORM 4 SHOULD BE FILED WITH PHILHEALTH WITHIN 90 CALENDAR DAYS FROM DATE OF DISCHARGE.

Name of Physician/Midwife:

Name of Facility:

Address of Facility:

Name of Patient:

POST-PARTUM CARE (date:__/__/__)

DONE

REMARKS

A. Check perineal wound healing

B. Check for signs of Maternal Postpartum complications

C. Check for signs of Newborn complications

D. Counselling and Education

1. Newborn Care

2. Breastfeeding and Nutrition

3. Newborn Immunization

4. Family Planning

E. Provide family planning service to patient if requested

F. Refer to Partner Physician for Voluntary Surgical Sterilization, if requested by patient

G. Schedule postpartum visit 6 weeks postpartum

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