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OB History and Physical
HPI – First sentence should include age, parity, gestational age (by dates/sono/size). Presents
with: presenting complaint with details.
When prenatal care began
Complications
PNC (prenatal care) labs
Pertinent negatives include presence of bleeding, ROM (rupture of membranes)
PMH – Operations/transfusions
Allergies
Medications
Habits
Infectious diseases (gonorrhea, Chlamydia, syphilis, herpes, genital warts, trichomonas,
HIV [when tested and result], PID, TB, rheumatic fever, hepatitis)
Medical illness
OB history – Include dates, type of delivery, sex/weight, complications of anesthesia
SH/FH/ROS
Physical exam – Vital signs, include FHT (fetal heart tones), also include fundal height and
cervical exam
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