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    OB Paperworks Guide

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    Mary Sheshira
    The document provides guidance on completing obstetric paperworks including an obstetric history, medical abstract, discharge summary, and Philhealth form (CF3). Key information to include in each form is outlined such as patient details, medical history, lab results, medications, physical exams, procedures, and hospital course. Accuracy is important as these forms provide an overview of the patient's obstetric care and will be given to the patient upon discharge.

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

    OB Paperworks Guide

    Uploaded by

    Mary Sheshira
    23 views26 pages
    The document provides guidance on completing obstetric paperworks including an obstetric history, medical abstract, discharge summary, and Philhealth form (CF3). Key information to include in each form is outlined such as patient details, medical history, lab results, medications, physical exams, procedures, and hospital course. Accuracy is important as these forms provide an overview of the patient's obstetric care and will be given to the patient upon discharge.

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    about ob gyn clerkship guide in brhmc

    Original Title

    OB-Paperworks-Guide

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    The document provides guidance on completing obstetric paperworks including an obstetric history, medical abstract, discharge summary, and Philhealth form (CF3). Key information to include in each form is outlined such as patient details, medical history, lab results, medications, physical exams, procedures, and hospital course. Accuracy is important as these forms provide an overview of the patient's obstetric care and will be given to the patient upon discharge.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    23 views26 pages

    OB Paperworks Guide

    Uploaded by

    Mary Sheshira
    The document provides guidance on completing obstetric paperworks including an obstetric history, medical abstract, discharge summary, and Philhealth form (CF3). Key information to include in each form is outlined such as patient details, medical history, lab results, medications, physical exams, procedures, and hospital course. Accuracy is important as these forms provide an overview of the patient's obstetric care and will be given to the patient upon discharge.

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    You are on page 1of 26

    OB Paperworks guide

    By Ti-An
    Paperworks
    • 1 Obstetric History
    • 2 Medical Abstract
    • 3 Discharge Summary
    • 1 CF3 (Philhealth)
    • Have a look at
    these to know who
    are your patients
    during the shift.
    • You will need this
    especially in the
    discharge summary
    Obstetric History
    • Has to be furnished as much as possible in
    the ER by the ER clerk.
    Note: Do not forget to place it in the
    patient chart before the chart is sent to
    the OR or at the DR
    Can be continued during duty by:
    • LR/DR clerk: if pt will undergo NSD
    • OB ward clerk: if will undergo CS once chart
    is available at the ward
    • Admitting Impression- Refer to ER Sheet
    • Do not copy the name of the patient from the ER sheet. Ask the patient herself. If
    there are misspelling of name in the ER sheet, double check it with the patient as
    well as her arm band, then report to the ER Doctor on duty.
    • History by: Write your name (ER clerk if you took the history)
    • MIDAS: Menarche, Interval, Duration, Amount, Signs and Symptoms
    • Use “+” sign if pt. has the history of the pertinent disease, and “-” sign if
    not.
    • Know how to compute for the gravidity and parity as well as the TPAL
    • LMP- First day of LMP
    • EDC: Naegeles rule
    • AOG: From LMP to present day
    • V/S: Refer to ER chart (Baseline)
    • EFW: Johnsons rule: (FH – n)155; n= floating:11, engaged=12 (please clarify this for I
    may had interchanged the n value. Thanks)
    Example
    • Use “+” sign or “–” sign
    • If ROS is unremarkable, place a straight line as shown in the next slide
    • This represents an unremarkable ROS
    • As been told to me, these are the necessary thing you need to fill in this part
    as well as the next slide. You may opt to fill up the others if you want
    • Data here are copied from:
    • Cover sheet
    • ER sheet
    • OB sheet
    • Laboratories
    • Dr’s Order
    • For the Diagnosis, you may also replace it with
    the Final dx.
    • Sorry for I made a wrong entry. As a nurse, that is how we do erasure. I
    asked Doc about this. She said it’s fine… But as much as possible refrain
    from errors.
    • Enumerate your positive findings for the ROS and PMHx (Past Medical Hx)
    if there are pertinent data just like how I enumerated for the FMHx (Family
    Hx)
    • For the labs refer to this 
    • For multiple laboratory results during
    hospital stay, place both results while
    placing the date on top.
    • For other labs, just enumerate the
    result in a bullet type form
    • This also applies to the Meds on Board in the Medical Abstract.
    • Use laymans terms and avoid abbreviations like BID, TID, OD, HS
    • This refers to the Oral Meds of the patient. Look at it in the Doctors Orders in the
    chart. Ask the nurse if you have a hard time finding this and there are no other clerk or
    the attending doctor around.
    • A copy of this will be given to
    the patient so right legibly
    here.
    • Data can be found also from
    where you got info in the med
    abstract
    • Course in the ward is a staple
    unless complicated. (Refer to
    the CF3 part of this pdf for a
    clearer guide)
    • This is CF3 for Philhealth
    • If patient is not
    experiencing any
    complication, the physical
    exam and course in the
    ward is a staple.
    • For V/S, refer to the ER chart
    What procedure?

    • The course in the ward for uncomplicated cases are staple so just copy this and fill out the
    part “Patient underwent… (Insert procedure done).
    P.S. I blocked out the procedure done to the patient so that you wont accidentally copy it
    • Just fill up:
    • 2.c
    • 2.d
    • 5
    • 9
    • 10
    • AMA- Advance Maternal Age (>35 y/o)

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