Fill Acog Prenatal Flow Sheet Pdf, download blank or editable online. Sign, fax and printable from PC, iPad, tablet or mobile with PDFfiller ✓ Instantly ✓ No. It’s Simple. Works with your current EHR and is easy to turn on. Start using it this week. Read More. ACOG Prenatal Record Flowsheet. These questions are covered the in ACOG prenatal record system, which lists . The findings should be recorded in a sequential flow-sheet to facilitate the.
|Published (Last):||11 September 2014|
|PDF File Size:||12.66 Mb|
|ePub File Size:||8.41 Mb|
|Price:||Free* [*Free Regsitration Required]|
Prenatal care is often the primary way young women access basic health care. With that in mind, one must look at prenatal care in the context of risk assessment, health promotion, and risk-directed intervention in general and not just from an obstetrical perspective.
This means that a large range of issues must be systematically and consistently addressed and documented during prenatal care. If one were to attempt to make an analogy between prenatal care and building a house, the prenatal record might be seen as the blueprint and checklist for construction, and the initial prenatal visit as the foundation and framework on which the rest of the structure is built.
Good prenatal care depends on many factors but clearly is facilitated by a good prenatal record. Additionally, the prenatal record both guides and documents the delivery of good prenatal care. Prenatal records have evolved considerably in the past three decades and may be better developed than any other specific medical record-keeping system.
The prenatal record and the initial prenatal evaluation are so closely linked that they must be discussed together. During the initial prenatal visit, the practitioner collects most of the information that will be used to evaluate obstetrical risks and determine what special interventions, if any, are needed.
This visit establishes the foundation for the physician—patient relationship, particularly when the patient is new to the physician. This chapter incorporates the elements of the first visit into the discussion of relevant portions of the prenatal record. The term initial prenatal visit is used here to identify the process of initiating prenatal care. This process actually may require two visits: This approach is considerably facilitated by a record system that clearly documents each step of the process and provides guidance for the practitioner so that omissions are avoided and problems are not overlooked.
Many different prenatal record forms are used throughout the United States. Prenatal records vary from simple notes made on blank sheets of paper to highly developed computer-based systems. Many offices and institutions develop their own prenatal record forms to fit the special needs and interests of the physicians using them.
The major disadvantage of individually developed record systems is that they often are not updated regularly as prenatal care practices change. There have been a great number of advances in prenatal care standards and screening practices, including first trimester genetic screening, multiple marker screening, universal hepatitis B screen, and an expanded genetics history and screening options. They are used by many institutions around the country and therefore facilitate the transfer of information.
They are revised and updated regularly, ensuring that the practitioner is using an up-to-date system. They incorporate risk assessment into the record system. The use of a standardized prenatal care system is one indication that good standardized prenatal care is being provided.
This can be beneficial in the event of medical or legal questions regarding the care provided. Several excellent standardized prenatal record systems are available. Several other good record systems have been developed and are available commercially either as electronic records or standard paper forms. Examples from nationally available record systems are used throughout this chapter to illustrate important components of the prenatal record.
All good prenatal record systems contain several well-defined components.
These sections usually are clearly identifiable and provide specific useful information. Basic demographic information includes the patient’s self-identified ethnicity, religious preference, educational background, age, and contact information.
Demographic information can be important in evaluating risk e. Patient age will alert the provider f,owsheet social issues e. It is becoming increasingly important for insurance information to be readily available with the heath record to facilitate appropriate referrals and clearances for testing and consultation for patients who participate in managed care plans. The first important historical information that obstetricians usually gather is the date of the first day of the last menstrual period LMP.
The record should reflect the accuracy of the date, cycle length, and normality of the LMP. Information on prior contraception and fertility treatment is important to determine the utility of the LMP to predict the estimated date of delivery EDD. Some record systems include a specific section for re-evaluating the EDD based on LMP, clinical estimators caog gestational age, and ultrasound information Fig.
Women’s Health Care Physicians
The first ultrasound in the pregnancy is the most accurate for dating purposes and should be used when establishing EDD. Changes in the EDD and the reasoning behind the change should be documented in the record. Many important management decisions in obstetric care rely on knowledge of the current estimated gestational age EGA.
Past pregnancy history is an important predictor of pregnancy risk in multiparous women. The elements that should be recorded include the dates of deliveries, types of deliveries vaginal or cesareanindication and type of uterine incision if a cesarean delivery was performed, birth weight and gestational age of previous infants, complications of previous pregnancies, and current state of health of previous children.
Additional details should be recorded in cases of complications. For example, a patient who experienced preterm delivery in the past should be queried regarding preterm rupture of membranes, preterm labor versus indicated delivery, or symptoms of an incompetent cervix.
It is important that a thorough medical history, covering conditions that could affect the pregnancy, be taken. Patients should be asked specifically about common medical conditions as well as uncommon conditions that are known to have a serious effect on pregnancy.
Common problems include diabetes, chronic hypertension, asthma, cardiac diseases including mitral valve prolapse, and hemoglobinopathies. Less common but equally important issues include lupus, thyroid disorders, chronic hepatitis, tuberculosis, bleeding disorders, chronic renal disease, cancer, or thromboembolic disorders.
A surgical history with emphasis on abdominal procedures flowsheft orthopedic procedures involving the pelvis should be taken. A history of prior ectopic pregnancy increases the risk of the current pregnancy being in an ectopic location. A history of uterine perforation or incision cornual resection or myomectomy may increase the need for a cesarean section as mode of delivery. A hip replacement flowsheeh present limitations in range of motion for patient positioning during delivery.
In flowsheet to questions about medical and surgical problems, complete prenatal care requires careful attention to specific areas e. Certain infections increase the risk of preterm delivery, congenital anomalies, and delivery complications. Advances in the Human Genome Project have made increasing numbers of genetic screening tests available for patients at risk. These questions are covered the in ACOG prenatal record system, which lists specific screening criteria Fig.
Although most pregnant women are healthy, illnesses that affect the reproductive age group can occur in pregnancy and include thyroid disorders, hepatitis, adnexal neoplasms, uterine fibroids, and even cancer e.
Therefore, a careful physical examination with clear documentation of findings is an important part of the initial prenatal visit.
Because the examination performed at this visit may be the first physical examination the patient has had in years, a complete screening examination is indicated. During the first fkowsheet, the physician can also provide education regarding any findings.
For example, a patient may have a number of dental caries that they have not had treated for fear flowaheet injuring the fetus; the physician can inform this patient that such treatment is not harmful.
A cardiac examination for murmurs or arrhythmia is important to rule out an acquired cardiac problem e. Marked scoliosis may increase symptoms of back problems throughout the pregnancy as well as increase the risk of acof pelvis abnormalities.
It is useful to note the presence of nipple abnormalities that may affect breastfeeding. A detailed pelvic examination is useful for documenting and confirming the gestational age determined by the LMP.
The Prenatal Record and the Initial Prenatal Visit | GLOWM
The pelvic examination should include cervical cytology if this study has not been performed within the past year. Assessments for gonorrhea and chlamydia are recommended by many flowshret.
The role of clinical pelvimetry in current practice is not clear and has not been studied in recent years. However, this brief, simple examination can be performed at the initial visit or be delayed until closer to delivery. The initial nutritional status and the ongoing quality of maternal nutrition during pregnancy are widely believed to affect the outcome of pregnancy.
Unfortunately, most physicians are poorly trained in assessing nutritional needs.
Patients with some medical problems have specific nutritional needs e. Referral to appropriate personnel for nutrition assessment and recommendations should be considered if there is concern about the nutritional status of the patient at the initial visit.
Increasing evidence suggests that psychosocial problems and social support may affect the occurrence of complications of pregnancy. Copyrighted by Hollister Incorporated, Libertyville, Illinois. The most commonly ordered prenatal laboratory studies for the initial visit are listed in Table 1. A good prenatal record system lists these studies in an organized format so that none will be overlooked by the practitioner. This practice reduces the likelihood of missing significant findings and facilitates retrieval of data by any other practitioner who cares for the patient.
A useful approach is to record the results of basic laboratory studies as they are performed e. Additional space should be available to record the results of any necessary follow-up or serial studies. One recent addition to the initial laboratory testing is the universal offering of human immunodeficiency virus HIV screening for all pregnant women.
The findings of the initial ultrasound evaluation should be documented and should include fetal number, EGA, placental location, and amniotic fluid volume. Depending on the EGA, the fetal presentation also may be important.
ACOG Prenatal Record – ACOG
It has become typical for a woman to receive at least one ultrasound examination during her pregnancy. In fact, this procedure is often included in the global fee for obstetrical care. The timing of the initial ultrasound in an otherwise uncomplicated pregnancy should be early enough to allow confirmation of gestational dating 20 floasheet but late enough to do a basic anatomy screen 16 weeks.
Scans done in the to week range are optimal for these reasons and also provide an opportunity to determine fetal gender. As regionalization of perinatal care developed aclg the accog, risk assessment was introduced as part of prenatal evaluation. Risk assessment is important for the identification of patients who require special care or referral to specialized facilities. Early risk-assessment systems divided patients into high-risk and low-risk groups.
This classification may be useful in systems in floswheet basic obstetric services are delivered by nurse practitioners, midwives, or family physicians, but it provides little specific guidance about diagnostic or therapeutic interventions. It is more useful to identify the risk of specific conditions e. Many published reports discuss specific factors that predict the risks of acgo conditions. The chapter on prenatal risk Toward perinatal electronic medical records for obstetrics assessment provides further information on this topic.
Patient education commonly is cited as important to achieving a good pregnancy outcome but often is overlooked flowshfet the course of a busy private practice. It probably is not necessary to document detailed educational material; it is sufficient to note the topics covered.
A separate manual of protocols details the actual information that is provided when a topic is covered. After the initial database is collected and evaluated, a management plan should be developed. For patients with an uncomplicated, low-risk pregnancy, this plan may be a standard prenatal care package.