Medical Record Form - Prenatal And Pregnancy
ADVERTISEMENT
1
2A
S
U
lbuquerque
ervice
nit: MEDICAL RECORD - PRENATAL and PREGNANCY
Patient’s Name:
______________________________________Age:_______ Tribe:__________________ Address:_____________________________________________
Phone: (H)
(W)
Father of Baby:
Tribe/Ethnicity:
Age:
Pregnancy History:
Grav:
Para:
Term:
Premature:
SAB:
TAB:
Living:
Stillbirth:
Neonatal Death:
GESTATIONAL AGE ASSESSMENTS:
LABORATORY FINDINGS
Date
Test
Result
Date
Test
Result
LMP:________________ Certain?__________________
Hct/Hgb
Hct
Type & Rh
RPR
Use of BCP’s: Yes
No
Last
Antibodies
UA
Taken?____________
Serology
UA C&S
Use of Depo: Yes
No
Last
HIV
Diabetes Screen
Taken?____________
HepBsAg
CLINIC EVALUATION:
Ultrasound scan:
Rubella
GBS
Diabetes Screen
Date___________ Gestational Age________________
UA & Micro
AFP/Triple Screen
Sonar EDC ___________________________________
UA C&S
_____________________________________________
Pap
Date___________ Gestational Age________________
GC
Predicted EDC:_______________
So
nar EDC__________________________________
__
Chlamydia
Reliability: Poor
Good
Excellent
Influenza Vaccine Date Given: _____________________
dT Date Given:___________________________
PRENATAL RISK ASSESSMENT:
Low Risk = Score 0-2
Medium Risk = Score 3-6
Extreme Risk = Score 7
REPRODUCTIVE HISTORY
ASSOCIATED CONDITIONS
PRESENT PREGNANCY
Age Under 16 or Over 35
1_________
Chronic Renal Disease
2_________
Bleeding:
Less than 20 wks
1_________
Parity 0 or Over 5
1_________
Diabetes: Gestational
2_________
After 20 wks
1-3_________
Habitual Abortion
1_________
Class B or Higher
3_________
Anemia: Hematocrit <34
1_________
Infertility
1_________
Cardiac Disease
1-3_________
Prolonged Pregnancy >42 wks
3_________
P P Hemorrhage, Manual Removal
1_________
Major Gyn Surgery, Cone Biopsy
2_________
Hypertension, Preeclampsia
2-3_________
Previous Baby >9lbs. (4050) gms)
1_________
______________________________
1-3_________
Premature Rupture of Membranes
3_________
<5½ lbs (2500 gms)
2_________
______________________________
1-3_________
Polydramnios
3_________
Previous Toxemia, Hypertension
1_________
______________________________
1-3_________
Small for Dates
3_________
Previous Cesarean Section
3_________
Cigarette Smoking________________
1_________
Multiple Pregnancy
3_________
Previous Stillbirth or N N D
3_________
Teratogen/Drug Exposure
1-2_________
Breech > 36 weeks
3_________
Prolonged Labor (> 30 Hrs.) or
Significant Social Problem
1-2_________
Rh Negative. Sensitized?
1-3_________
Difficult Delivery
1_________
______________________________
Genital Herpes, active
___________________________
1_________
Alcohol Use Screens______________
1-2_________
Excessive or inadequate wt. gain
1-2_________
____________________________
1_________
Domestic Violence Screens________
1-2_________
____________________________
1-3_________
Obstetric Prognosis and Management Plan for at Risk Conditions:
PRENATAL RECORD
Ht:________
DATE
Estimated Weeks Gestation D/S
WT. Pre_______ Preg________
Blood Pressure
Fundal Height
Position
Fetal Movement
Fetal Heart: FS-DOP
Edema
UA: Protein
Risk Assessment
Provider Initials
Patient’s Identification
Signature Code: Initials
Signature & Title
WIC: Yes
No
Medicaid: Yes
No
Hospital for Delivery:
Labor Support:
Childbirth Education:
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical