SAMPLE: ACOG Antepartum Record

DATE
NAME
LAST
FIRST
MIDDLE
ID#
HOSPITALOFDELIVERY
NEWBORN’SPHYSICIAN
REFERREDBY
FINALEDD
PRIMARYPROVIDER/GROUP
BIRTHDATE
AGE
RACE
MARITALSTATUS
S
OCCUPATION
ADDRESS
SEP
(LASTGRADECOMPLETED)
HOMEMAKER
OUTSIDEWORK
STUDENT
TypeofWork
HUSBAND/FATHEROFBABY
TOTALPREG
M W
D
EDUCATION
PHONE
FULLTERM
PREMATURE
PHONE
EMERGENCYCONTACT
AB.INDUCED
AB.SPONTANEOUS
(O)
(H)
ZIP
PHONE
INSURANCECARRIER/MEDICAID#
ECTOPICS
MULTIPLEBIRTHS
LIVING
MENSTRUALHISTORY
LMP
DEFINITE
UNKNOWN
APPROXIMATE(MONTHKNOWN)
MENESMONTHLY
NORMALAMOUNT/DURATION
PRIORMENES
YES
NO
FREQUENCY:Q
DATE
ONBCPATCONCEPT.
DAYS
YES
MENARCHE
NO
hCG+
(AGEONSET)
/
/
FINAL
PASTPREGNANCIES(LASTSIX)
DATE
GA
MONTH/ WEEKS
YEAR
LENTGH BIRTH
OF
WEIGHT
LABOR
SEX
M/F
TYPE
DELIVERY
ANES
PRETERM
LABOR
YES/NO
PLACEOF
DELIVERY
COMMENTS/COMPLICATIONS
PASTMEDICALHISTORY
ONeg
+Pos
DETAILPOSITIVEREMARKS
INCLUDEDATE&TREATMENT
ONeg
+Pos
1.DIABETES
16.D(Rh)SENSITIZED
2.HYPERTENSION
17.PULMONARY(TB,ASTHMA)
3.HEARTDISEASE
18.ALLERGIES(DRUGS)
4.AUTOIMMUNEDISORDER
19.BREAST
5.KIDNEYDISEASE/UTI
20.GYNSURGERY
6.NEUROLOGIC/EPILEPSY
7.PSYCHIATRIC
8.HEPATITIS/LIVERDISEASE
21.OPERATION/HOSPITALIZATIONS
(YEAR&REASON)
9.VARICOSITIES/PHLEBITIS
10.THYROIDDYSFUNCTION
22.ANESTHETICCOMPLICATIONS
11.TRAUMA/DOMESTICVIOLENCE
23.HISTORYOFABNORMALPAP
12.HISTORYOFBLOODTRANSFUS
AMT/DAY
PREPREG
AMT/DAY
PREPREG
#YEARS
USE
24.UTERINEANOMALY/DES
13.TOBACCO
25.INFERTILITY
14.ALCOHOL
26.RELEVANTFAMILYHISTORY
15.STREETDRUGS
27.OTHER
COMMENTS:
TheAmericanCollegeofObstetriciansansGynecologists40912thStreetSWPOBox96920WashingtonDC20090-6920
DETAILPOSITIVEREMARKS
INCLUDEDATE&TREATMENT
SYMPTOMSSINCELMP
YES
NO
YES
NO
12.MENTALRETARDATION/AUTISM
1.PATIENT’SAGE(35OROLDER)
2.THALASSEMIA(ITALIAN,GREEK,MEDITERRANEAN,ORASIAN
BACKGROUND)MCV<80
IFYES,WASPERSONTREATEDFORFRAGILEX?
13.OTHERINHERITEDGENETICORCHROMOSOMALDISORDER
3.NEURALTUBEDEFECT
(MENINGOMYELOCELE,SPINABIFIDA,ORANENCEPHALY)
14.MATERNALMETABOLICDISORDER(EG.INSULINDEPENDENT
DIABETES,PKU)
4.CONGENITALHEARTDEFECT
5.DOWNSYNDROME
15.PATIENTORBABY’SFATHERHADACHILDWITHBIRTHDEFECTS
NOTLISTEDABOVE
6.TAY-SACHS(EG.JEWISH,CAJUN,FRENCH-CANADIAN
16.RECURRENTPREGNANCYLOSS,ORASTILLBIRTH
7.SICKLECELLDISEASEORTRAIT(AFRICAN)
17.MEDICATIONS/STREETDRUGS/ALCOHOLSINCELASTMENSTRUAL
PERIOD
8.HEMOPHILIA
IFYES,AGENT(S)
9.MUSCULARDYSTROPHY
10.CYSTICFIBROSIS
18.ANYOTHER
11.HUNTINGTONCHOREA
COMMENTS/COUNSELING
INFECTIONHISTORY
YES
NO
YES
1.HIGHRISKHEPATITISB/IMMUNIZED?
4.RASHORVIRALILLNESSSINCELASTMENSTRUALPERIOD
2.LIVEWITHSOMEONEWITHTBOREXPOSEDTOTB
5.HISTORYOFSTD.GC.CHLAMYDIAHPV.SYPHILIS
3.PATIENTORPARTNERHASHISTORYOFGENITALHERPES
6.OTHER(SEECOMMENTS
NO
COMMENTS
INTERVIEWER’SSIGNATURE
INITIALPHYSICALEXAMINATION
DATE
/
/
PREPREGNANCYWEIGHT
HEIGHT
BP
1.HEENT
NORMAL
ABNORMAL
12.VULVA
NORMAL
ABNORMAL
2.FUNDI
NORMAL
ABNORMAL
13.VAGINA
NORMAL
ABNORMAL
3.TEETH
NORMAL
ABNORMAL
14.CERVIX
NORMAL
ABNORMAL
4.THYROID
NORMAL
ABNORMAL
15.UTERUSSIZE
NORMAL
ABNORMAL
5.BREASTS
NORMAL
ABNORMAL
16.ADNEXA
NORMAL
ABNORMAL
6.LUNGS
NORMAL
ABNORMAL
17.RECTUM
NORMAL
ABNORMAL
7.HEART
NORMAL
ABNORMAL
18.DIAGONALCONJUGATE
NORMAL
ABNORMAL
8.ABDOMEN
NORMAL
ABNORMAL
19.SPINES
NORMAL
ABNORMAL
9.EXTREMITIES
NORMAL
ABNORMAL
20.SACRUM
NORMAL
ABNORMAL
10.SKIN
NORMAL
ABNORMAL
21.SUBPUBICARCH
NORMAL
ABNORMAL
ABNORMAL
22.GYNECODPELVICTYPE
NORMAL
ABNORMAL
11.LYMPHNODE
NORMAL
COMMENTS (Numberandexplainabnormals)
EXAMBY
TheAmericanCollegeofObstetriciansansGynecologists40912thStreetSWPOBox96920WashingtonDC20090-6920
NAME
LAST
FIRST
MIDDLE
DRUGALLERGY
RELIGIOUS/CULTURALCONSIDERATIONS
ANESTHESIACONSULTPLANNED
PROBLEMS/PLANS
MEDICATIONLIST:
1.
1.
2.
2.
3.
3.
4.
4.
5.
5.
6.
YES
StartDate
NO
StopDate
6.
EDDCONFIRMATION
INITIALEDD:
LMP
/
/
INITIALEXAM
/
/
=
ULTRASOUND
/
/
=
INITIALEDD
/
/
18-20-WEEKEDDUPDATE:
/
/
+22WKS =
/
/
= EDD
/
/
FUNDALHT.ATUMBIL
/
/
+20WKS =
/
/
WKS = EDD
/
/
FHTW/FETOSCOPE
/
/
+20WKS =
/
/
WKS = EDD
/
/
ULTRASOUND
/
/
=
WKS =
/
/
FINALEDD
/
/
INITIALEDBY
QUICKENING
INITIALEDBY
VISITDATE
(YEAR)
COMMENTS:
PROBLEMS:
COMMENTS:
TheAmericanCollegeofObstetriciansansGynecologists40912thStreetSWPOBox96920WashingtonDC20090-6920
LABORATORYANDEDUCATION
INITIALLABS
DATE
RESULT
BLOODTYPE
/
/
D(Rh)TYPE
/
/
ANTIBODYSCREEN
/
/
HCT/HGB
/
/
PAPTEST
/
/
RUBELLA
/
/
VDRL
/
/
URINECULTURE/SCREEN
/
/
HBsAg
/
/
HIVCOUNSELING/TESTING
/
/
OPTIONALLABS
B
/
/
/
/
/
/
GC
/
/
TAY-SACHS
/
/
OTHER
/
%
POS
AA
NEG
AS
DECLINED
SS
AC
REVIEWED
SC
Ta2
AF
/
RESULT
ULTRASOUND
/
/
MSAFP/MULTIPLEMARKERS
/
/
AMNIO/CVS
/
/
KARYOTYPE
/
/
46.XX
AMINOTICFLUID(AFP)
/
/
NORMAL
OR
46.XY
REVIEWED
/ OTHER
ABNORMAL
DATE
2 4 - 2 8 - W E E K L A B S (WHENINDICATED)
g/dl
COMMENTS/ADDITIONALLABS
DATE
(WHENINDICATED)
O
RESULT
PPD
CHLAMYDIA
AB
NORMAL/ABNORMAL/
DATE
HGBELECTROPHORESIS
8-18-WEEKLABS
A
REVIEWED
RESULT
REVIEWED
HCT/HGB
/
/
%
DIABETESSCREEN
/
/
1HOUR
GTT(IFSCREENABNORMAL)
/
/
FBS
1HOUR
2HOUR
3HOUR
D(Rh)ANTIBODYSCREEN
/
/
DIMMUNEGLOBULIN(RhIG)GIVEN(28WKS)
/
/
3 2 - 3 6 - W E E K L A B S (WHENINDICATED)
DATE
SIGNATURE
RESULT
HCT/HGB(RECOMMENDED)
/
/
ULTRASOUND
/
/
VDRL
/
/
GC
/
/
CHLAMYDIA
/
/
GROUPBSTREP(35-37WKS)
/
/
PLANS/EDUCATION (COUNSELED
g/dl
REVIEWED
%
g/dl
)
ANESTHESIAPLANS
TUBALSTERILIZATION
TOXOPLASMOSISPRECAUTIONS(CATS/RAWMEAT)
VSACCOUNSELING
CHILDBIRTHCLASSESS
CIRCUMCISION
PHYSICAL/SEXUALACTIVITY
TRAVEL
LABORSIGNS
NUTRITIONCOUNSELING
LIFESTYLE,TOBACCO,ALCOHOL
REQUESTS
BREASTORBOTTLEFEEDING
NEWBORNCARSEAT
POSTPARTUMBIRTHCONTROL
ENVIRONMENTAL/WORKHAZARDS
TUBALSTERILIZATION
CONSENTSIGNED
PROVIDERSIGNATURE(ASREQUIRED)
TheAmericanCollegeofObstetriciansansGynecologists40912thStreetSWPOBox96920WashingtonDC20090-6920
DATE
/
INITIALS
/
NAME
LAST
FIRST
MIDDLE
ID#
SupplementalVisits
VISITDATE
(YEAR)
COMMENTS:
Progress Notes
PROVIDERSIGNATURE(REQUIRED)
TheAmericanCollegeofObstetriciansansGynecologists40912thStreetSWPOBox96920WashingtonDC20090-6920
NAME
LAST
MIDDLE
FIRST
ID#
ProgressNotes
PROVIDERSIGNATURE(REQUIRED)
TheAmericanCollegeofObstetriciansansGynecologists40912thStreetSWPOBox96920WashingtonDC20090-6920