Download ACOG ANTEPARTUM RECORD (FORM A)

Patient Addressograph
DATE
NAME
LAST
FIRST
ID #
MIDDLE
HOSPITAL OF DELIVERY
NEWBORN’S PHYSICIAN
REFERRED BY
FINAL EDD
PRIMARY PROVIDER/GROUP
BIRTH DATE
AGE
RACE
ADDRESS
MARITAL STATUS
S M W D SEP
MONTH DAY YEAR
OCCUPATION
EDUCATION
(LAST GRADE COMPLETED)
ZIP
LANGUAGE
PHONE
(H)
INSURANCE CARRIER/MEDICAID #
HUSBAND/DOMESTIC PARTNER
PHONE
POLICY #
FATHER OF BABY
PHONE
EMERGENCY CONTACT
TOTAL PREG
FULL TERM
PREMATURE
AB, INDUCED
AB, SPONTANEOUS
PHONE
E
L
ECTOPICS
MENSTRUAL HISTORY
LMP
■
■
■
DEFINITE
UNKNOWN
■ APPROXIMATE (MONTH KNOWN)
■ NORMAL AMOUNT/DURATION
MENSES MONTHLY
■
YES
■
PRIOR MENSES _________ DATE
NO
FREQUENCY: Q _________ DAYS
ON BCP AT CONCEPT
■
YES
GA
WEEKS
LENGTH
OF
LABOR
BIRTH
WEIGHT
SEX
M/F
P
M
TYPE
DELIVERY
ANES.
PRETERM
LABOR
YES/NO
2. HYPERTENSION
3. HEART DISEASE
NO
hCG + _____/_____/_____
COMMENTS/
COMPLICATIONS
MEDICAL HISTORY
● Neg.
+ Pos.
DETAIL POSITIVE REMARKS
INCLUDE DATE & TREATMENT
1. DIABETES
LIVING
DETAIL POSITIVE REMARKS
INCLUDE DATE & TREATMENT
17. D (Rh) SENSITIZED
18. PULMONARY (TB, ASTHMA)
19. SEASONAL ALLERGIES
20. DRUG/LATEX ALLERGIES/
REACTIONS
4. AUTOIMMUNE DISORDER
ACOG ANTEPARTUM RECORD (FORM A)
A
S
● Neg.
+ Pos.
PLACE OF
DELIVERY
MULTIPLE BIRTHS
MENARCHE _______________ (AGE ONSET)
■
FINAL ________
PAST PREGNANCIES (LAST SIX)
DATE
MONTH/
YEAR
(O)
5. KIDNEY DISEASE/UTI
6. NEUROLOGIC/EPILEPSY
21. BREAST
7. PSYCHIATRIC
22. GYN SURGERY
8. DEPRESSION/POSTPARTUM
DEPRESSION
23. OPERATIONS/
HOSPITALIZATIONS
(YEAR & REASON)
9. HEPATITIS/LIVER DISEASE
10. VARICOSITIES/PHLEBITIS
11. THYROID DYSFUNCTION
24. ANESTHETIC COMPLICATIONS
12. TRAUMA/VIOLENCE
25. HISTORY OF ABNORMAL PAP
13. HISTORY OF BLOOD TRANSFUS.
26. UTERINE ANOMALY/DES
AMT/DAY
PREPREG
14. TOBACCO
AMT/DAY
PREG
# YEARS
USE
27. INFERTILITY
28. RELEVANT FAMILY HISTORY
15. ALCOHOL
16. ILLICIT/RECREATIONAL DRUGS
29. OTHER
COMMENTS
Version 5. Copyright © 2003 The American College of Obstetricians and Gynecologists, 409 12th Street, SW, PO Box 96920, Washington, DC 20090-6920
AA128
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Patient Addressograph
SYMPTOMS SINCE LMP
GENETIC SCREENING/TERATOLOGY COUNSELING
E
L
INCLUDES PATIENT, BABY'S FATHER, OR ANYONE IN EITHER FAMILY WITH:
YES
NO
1. PATIENT'S AGE ≥ 35 YEARS AS OF ESTIMATED DATE OF DELIVERY
12. HUNTINGTON’S CHOREA
2. THALASSEMIA (ITALIAN, GREEK, MEDITERRANEAN, OR
ASIAN BACKGROUND): MCV <80
13. MENTAL RETARDATION/AUTISM
YES
NO
YES
NO
IF YES, WAS PERSON TESTED FOR FRAGILE X?
3. NEURAL TUBE DEFECT
(MENINGOMYELOCELE, SPINA BIFIDA, OR ANENCEPHALY)
14. OTHER INHERITED GENETIC OR CHROMOSOMAL DISORDER
4. CONGENITAL HEART DEFECT
15. MATERNAL METABOLIC DISORDER (EG, TYPE 1 DIABETES, PKU)
P
M
16. PATIENT OR BABY'S FATHER HAD A CHILD WITH BIRTH DEFECTS
NOT LISTED ABOVE
5. DOWN SYNDROME
6. TAY–SACHS (EG, JEWISH, CAJUN, FRENCH CANADIAN)
17. RECURRENT PREGNANCY LOSS, OR A STILLBIRTH
7. CANAVAN DISEASE
18. MEDICATIONS (INCLUDING SUPPLEMENTS, VITAMINS, HERBS OR
OTC DRUGS)/ILLICIT/RECREATIONAL DRUGS/ALCOHOL SINCE
LAST MENSTRUAL PERIOD
8. SICKLE CELL DISEASE OR TRAIT (AFRICAN)
9. HEMOPHILIA OR OTHER BLOOD DISORDERS
IF YES, AGENT(S) AND STRENGTH/DOSAGE
10. MUSCULAR DYSTROPHY
19. ANY OTHER
11. CYSTIC FIBROSIS
A
S
COMMENTS/COUNSELING
INFECTION HISTORY
1. LIVE WITH SOMEONE WITH TB OR EXPOSED TO TB
2. PATIENT OR PARTNER HAS HISTORY OF GENITAL HERPES
YES
NO
4. HISTORY OF STD, GONORRHEA, CHLAMYDIA, HPV, SYPHILIS
5. OTHER (See Comments)
3. RASH OR VIRAL ILLNESS SINCE LAST MENSTRUAL PERIOD
COMMENTS
INTERVIEWER’S SIGNATURE
DATE ________ / ________ / ________
HEIGHT ___________
BP__________
1. HEENT
■
NORMAL
■
ABNORMAL
12. VULVA
■
NORMAL
■
CONDYLOMA
■
LESIONS
2. FUNDI
■
NORMAL
■
ABNORMAL
13. VAGINA
■
NORMAL
■
INFLAMMATION
■
DISCHARGE
3. TEETH
■
NORMAL
■
ABNORMAL
14. CERVIX
■
NORMAL
■
INFLAMMATION
■
LESIONS
4. THYROID
■
NORMAL
■
ABNORMAL
15. UTERUS SIZE
__________ WEEKS
■
FIBROIDS
5. BREASTS
■
NORMAL
■
ABNORMAL
16. ADNEXA
■
NORMAL
■
MASS
6. LUNGS
■
NORMAL
■
ABNORMAL
17. RECTUM
■
NORMAL
■
ABNORMAL
7. HEART
■
NORMAL
■
ABNORMAL
18. DIAGONAL CONJUGATE
■
REACHED
■
NO
__________ CM
8. ABDOMEN
■
NORMAL
■
ABNORMAL
19. SPINES
■
AVERAGE
■
PROMINENT
■
BLUNT
9. EXTREMITIES
■
NORMAL
■
ABNORMAL
20. SACRUM
■
CONCAVE
■
STRAIGHT
■
ANTERIOR
10. SKIN
■
NORMAL
■
ABNORMAL
21. SUBPUBIC ARCH
■
NORMAL
■
WIDE
■
NARROW
11. LYMPH NODES
■
NORMAL
■
ABNORMAL
22. GYNECOID PELVIC TYPE
■
YES
■
NO
COMMENTS (Number and explain abnormals)
EXAM BY
ACOG ANTEPARTUM RECORD (FORM B)
INITIAL PHYSICAL EXAMINATION
Patient Addressograph
NAME
LAST
FIRST
DRUG ALLERGY
MIDDLE
LATEX ALLERGY
IS BLOOD TRANSFUSION ACCEPTABLE IN AN EMERGENCY?
■ YES
■ NO
■ YES
ANESTHESIA CONSULT PLANNED
■ NO
PROBLEMS/PLANS
MEDICATION LIST
Start date
1.
1.
______ / ______ / ______
______ / ______ / ______
2.
2.
______ / ______ / ______
______ / ______ / ______
3.
3.
______ / ______ / ______
______ / ______ / ______
4.
4.
______ / ______ / ______
______ / ______ / ______
5.
5.
______ / ______ / ______
______ / ______ / ______
6.
6.
______ / ______ / ______
______ / ______ / ______
18–20-WEEK EDD UPDATE
INITIAL EDD
LMP
______ / ______ / ______
E
L
P
M
EDD CONFIRMATION
Stop date
=
EDD ______ / ______ / ______
QUICKENING
_______ / _______ / _______
+22 WKS =
_______ / _______ / _______
_______ / _______ / _______
+20 WKS =
_______ / _______ / _______
______ / ______ / ______ = ______ WKS = EDD ______ / ______ / ______
ULTRASOUND
______ / ______ / ______ = ______ WKS = EDD ______ / ______ / ______
ULTRASOUND
_______ / _______ / _______ = _______ WKS = _______ / _______ / _______
INITIAL EDD
______ / ______ / ______
FINAL EDD
_______ / _______ / _______
COMMENTS
(A
LB
UM
NE
IN
/G
XT
LU
AP
CO
PO
SE
IN
)
TM
PR
EN
O
VI
T
DE
R
(IN
IT
IA
LS
)
FE
TA
L
FU
N
D
AL
W
EE
KS
PROBLEMS
COMMENTS
ACOG ANTEPARTUM RECORD (FORM C)
A
S
INITIALED BY __________________________
UR
IN
E
INITIALED BY _______________________
M
O
VE
PR
M
ET
EN
SI E
T
G RM
N
+= S L
PR /SY AB
ES MP OR
EN TO
CE
T M
RV
●
=A S:
UL IX
TR E
BS
AS XA
EN
O M
T
UN (D
I
D L.
BL
LE /EF
O
O
NG F.
D
TH STA
PR
.)
ES
S
W
UR
EI
E
G
HT
G
ES
T.
_______________
H
EI
G
H
T
(B
ES
T
ES
T.)
PREPREGNANCY
WEIGHT
PR
ES
(C
EN
M
)
TA
TI
O
N
FH
R
INITIAL EXAM
FUNDAL HT.
AT UMBIL.
Patient Addressograph
LABORATORY AND EDUCATION
INITIAL LABS
DATE
RESULT
BLOOD TYPE
/
/
D (Rh) TYPE
/
/
ANTIBODY SCREEN
/
/
HCT/HGB
/
/
__________ % _________ g/dL
PAP TEST
/
/
NORMAL/ABNORMAL/________
RUBELLA
/
/
VDRL
/
/
URINE CULTURE/SCREEN
/
/
HBsAg
/
/
HIV COUNSELING/TESTING*
/
/
OPTIONAL LABS
/
PPD
/
/
CHLAMYDIA
/
/
GONORRHEA
/
/
GENETIC SCREENING TESTS (SEE FORM B)
/
/
O
DATE
NEG.
DECLINED
AA AS SS AC SC AF
↓
A2
RESULT
ULTRASOUND
/
/
MSAFP/MULTIPLE MARKERS
/
/
AMNIO/CVS
/
/
KARYOTYPE
/
/
46,XX OR 46,XY/OTHER_______
AMNIOTIC FLUID (AFP)
/
/
NORMAL_____ ABNORMAL_____
24–28-WEEK LABS (WHEN INDICATED)
DATE
RESULT
/
/
__________ % _________ g/dL
DIABETES SCREEN
/
/
1 HOUR______________________
GTT (IF SCREEN ABNORMAL)
/
/
______FBS
______1 HOUR
______2 HOUR
______3 HOUR
/
/
ANTI-D IMMUNE GLOBULIN (RhlG)
GIVEN (28 WKS)
/
/
SIGNATURE
________________________________
32–36-WEEK LABS
DATE
RESULT
HCT/HGB
/
/
ULTRASOUND (WHEN INDICATED)
/
/
VDRL (WHEN INDICATED)
/
/
GONORRHEA (WHEN INDICATED)
/
/
CHLAMYDIA (WHEN INDICATED)
/
/
GROUP B STREP
/
/
*Check state requirements before recording results.
PROVIDER SIGNATURE (AS REQUIRED)
__________ % _________ g/dL
ACOG ANTEPARTUM RECORD (FORM D)
HCT/HGB
D (Rh) ANTIBODY SCREEN
E
L
P
M
POS.
A
S
(WHEN INDICATED/
AB
RESULT
/
8–18-WEEK LABS ELECTED)
B
COMMENTS/ADDITIONAL LABS
DATE
HGB ELECTROPHORESIS
OTHER
A
REVIEWED
Patient Addressograph
NAME
LAST
PLANS/EDUCATION
(COUNSELED ■ )—BY TRIMESTER.
FIRST
MIDDLE
INITIAL AND DATE WHEN DISCUSSED.
FIRST TRIMESTER
■
HIV AND OTHER ROUTINE PRENATAL TESTS
■
RISK FACTORS IDENTIFIED BY PRENATAL HISTORY
■
ANTICIPATED COURSE OF PRENATAL CARE
■
NUTRITION AND WEIGHT GAIN COUNSELING
■
TOXOPLASMOSIS PRECAUTIONS (CATS/RAW MEAT)
■
SEXUAL ACTIVITY
■
EXERCISE
■
ENVIRONMENTAL/WORK HAZARDS
■
TRAVEL
■
TOBACCO (ASK, ADVISE, ASSESS, ASSIST, AND ARRANGE)
■
ALCOHOL
■
ILLICIT/RECREATIONAL DRUGS
■
USE OF ANY MEDICATIONS (INCLUDING SUPPLEMENTS, VITAMINS, HERBS, OR OTC DRUGS)
■
INDICATIONS FOR ULTRASOUND
■
DOMESTIC VIOLENCE
■
SEAT BELT USE
■
CHILDBIRTH CLASSES/HOSPITAL FACILITIES
SIGNS AND SYMPTOMS OF PRETERM LABOR
■
ABNORMAL LAB VALUES
■
INFLUENZA VACCINE
■
SELECTING A PEDIATRICIAN
■
POSTPARTUM FAMILY PLANNING/TUBAL STERILIZATION
E
L
P
M
SECOND TRIMESTER
■
NEED FOR
FURTHER DISCUSSION
COMPLETED
■
ANESTHESIA/ANALGESIA PLANS
■
FETAL MOVEMENT MONITORING
■
LABOR SIGNS
■
VBAC COUNSELING
■
SIGNS AND SYMPTOMS OF PREGNANCY-INDUCED HYPERTENSION
■
POSTTERM COUNSELING
■
CIRCUMCISION
■
BREAST OR BOTTLE FEEDING
■
POSTPARTUM DEPRESSION
■
NEWBORN CAR SEAT
■
FAMILY MEDICAL LEAVE OR DISABILITY FORMS
ACOG ANTEPARTUM RECORD (FORM E)
A
S
THIRD TRIMESTER
REQUESTS
TUBAL STERILIZATION CONSENT SIGNED
HISTORY AND PHYSICAL HAS BEEN SENT TO HOSPITAL, IF APPLICABLE.
DATE
INITIALS
____/____/____
____________
DATE
INITIALS
____/____/____
____________
Version 5. Copyright © 2002 The American College of Obstetricians and Gynecologists, 409 12th Street, SW, PO Box 96920, Washington, DC 20090-6920
AA128
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Patient Addressograph
Plans/Education Notes
E
L
ACOG ANTEPARTUM RECORD (FORM E, continued)
A
S
P
M
Patient Addressograph
NAME
LAST
FIRST
MIDDLE
ID #
EDD
(A
LB
UM
NE
IN
/G
XT
LU
AP
CO
PO
SE
IN
)
TM
PR
EN
O
VI
T
DE
R
(IN
IT
IA
LS
)
E
L
UR
IN
E
M
O
VE
PR
M
ET
EN
SI E
T
G RM
N
+= S L
PR /SY AB
ES MP OR
EN TO
CE
T M
RV
●
=A S:
UL IX
TR E
BS
AS XA
EN
O M
T
UN (D
I
D L.
BL
LE /EF
O
O
NG F.
D
TH STA
PR
.)
ES
S
W
UR
EI
E
G
HT
FU
N
D
AL
W
EE
KS
G
ES
T.
_______________
FE
TA
L
(B
ES
T
PREPREGNANCY
WEIGHT
ES
H
T.)
EI
G
H
PR
T
ES
(C
EN
M
)
TA
TI
O
N
FH
R
Supplemental Visits
COMMENTS
P
M
Progress Notes
ACOG ANTEPARTUM RECORD (FORM F)
A
S
PROVIDER SIGNATURE (AS REQUIRED)
Version 5. Copyright © 2002 The American College of Obstetricians and Gynecologists, 409 12th Street, SW, PO Box 96920, Washington, DC 20090-6920
AA128
12345/76543
G
ES
T.
PREPREGNANCY
WEIGHT
A
S
Progress Notes
(A
LB
UM
NE
IN
/G
XT
LU
AP
CO
PO
SE
IN
)
TM
PR
EN
O
VI
T
DE
R
(IN
IT
IA
LS
)
UR
IN
E
FIRST
P
M
ACOG ANTEPARTUM RECORD (FORM F, continued)
PROVIDER SIGNATURE (AS REQUIRED)
M
O
VE
PR
M
ET
EN
SI E
T
G RM
N
+= S L
PR /SY AB
ES MP OR
EN TO
CE
T M
RV
●
=A S:
UL IX
TR E
BS
AS XA
EN
O M
T
UN (D
I
D L.
BL
LE /EF
O
O
NG F.
D
TH STA
PR
.)
ES
S
W
UR
EI
E
G
HT
LAST
FE
TA
L
ES
H
T.)
EI
G
H
PR
T
ES
(C
EN
M
)
TA
TI
O
N
FH
R
(B
ES
T
_______________
FU
N
D
AL
W
EE
KS
Patient Addressograph
NAME
MIDDLE
ID #
EDD
visits
Supplemental Visits
COMMENTS
E
L
Patient Addressograph
NAME
LAST
FIRST
MIDDLE
ID #
Progress Notes
E
L
P
M
ACOG ANTEPARTUM RECORD (FORM G)
A
S
PROVIDER SIGNATURE (AS REQUIRED)
Version 5. Copyright © 2002 The American College of Obstetricians and Gynecologists, 409 12th Street, SW, PO Box 96920, Washington, DC 20090-6920
AA128
12345/76543
Patient Addressograph
NAME
LAST
FIRST
MIDDLE
ID #
Progress Notes
E
L
P
M
PROVIDER SIGNATURE (AS REQUIRED)
ACOG ANTEPARTUM RECORD (FORM G, continued)
A
S