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    Prenatal Card

    Uploaded by

    Mandeep Singh
    This medical record document contains forms for documenting a patient's prenatal care and pregnancy. The forms include sections for collecting: the patient's demographic and contact information; pregnancy history; assessments of gestational age like last menstrual period and ultrasound dates; laboratory test results; prenatal risk assessment through scoring of medical and pregnancy factors; and spaces to record information from prenatal visits like vital signs, fetal position and heart rate, risk level, and provider notes. The document contains all the elements needed to comprehensively track a patient's prenatal health and care.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Prenatal Card

    Uploaded by

    Mandeep Singh
    434 views2 pages
    This medical record document contains forms for documenting a patient's prenatal care and pregnancy. The forms include sections for collecting: the patient's demographic and contact information; pregnancy history; assessments of gestational age like last menstrual period and ultrasound dates; laboratory test results; prenatal risk assessment through scoring of medical and pregnancy factors; and spaces to record information from prenatal visits like vital signs, fetal position and heart rate, risk level, and provider notes. The document contains all the elements needed to comprehensively track a patient's prenatal health and care.

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    Prenatal Card

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    This medical record document contains forms for documenting a patient's prenatal care and pregnancy. The forms include sections for collecting: the patient's demographic and contact information; pregnancy history; assessments of gestational age like last menstrual period and ultrasound dates; laboratory test results; prenatal risk assessment through scoring of medical and pregnancy factors; and spaces to record information from prenatal visits like vital signs, fetal position and heart rate, risk level, and provider notes. The document contains all the elements needed to comprehensively track a patient's prenatal health and care.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    434 views2 pages

    Prenatal Card

    Uploaded by

    Mandeep Singh
    This medical record document contains forms for documenting a patient's prenatal care and pregnancy. The forms include sections for collecting: the patient's demographic and contact information; pregnancy history; assessments of gestational age like last menstrual period and ultrasound dates; laboratory test results; prenatal risk assessment through scoring of medical and pregnancy factors; and spaces to record information from prenatal visits like vital signs, fetal position and heart rate, risk level, and provider notes. The document contains all the elements needed to comprehensively track a patient's prenatal health and care.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
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    Albuquerque Service Unit: 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

    28 Wk Lab
    Type & Rh RPR
    Use of BCP’s: Yes ❒ No ❒ Last
    Antibodies UA
    Taken?____________

    First Prenatal Lab


    Serology UA C&S
    Use of Depo: Yes ❒ No ❒ Last
    Taken?____________ HIV Diabetes Screen
    HepBsAg
    CLINIC EVALUATION: Ultrasound scan: Rubella GBS
    Diabetes Screen
    Date___________ Gestational Age________________

    Other Lab
    UA & Micro AFP/Triple Screen
    Sonar EDC ___________________________________ UA C&S
    _____________________________________________
    Pap
    Date___________ Gestational Age________________
    GC
    Predicted
    Sonar EDC:_______________ __
    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:
    Albuquerque Service Unit: 10/2000 (Revised IHS-800-1) Page 1

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