Headings
Gestational age · Interval history · Vital signs · Fundal height · Fetal heart rate · Results reviewed · Counseling · Plan · Next visit
When to use it
Use this for routine visits during pregnancy when you provide prenatal care in a family practice. It tracks gestational age, fundal height and fetal heart rate at every visit, then records the labs and counseling that come due at each stage. It is a repeating visit format, not a first intake or delivery record.
Example
Fictional example
Gestational age
28 weeks 2 days by first trimester ultrasound.
Interval history
E.F., 31, G2P1. Good fetal movement. No bleeding, leaking fluid or contractions. Mild heartburn.
Vital signs
BP 116/72. Weight up 1.5 lb in 2 weeks.
Fundal height
28 cm.
Fetal heart rate
144 beats per minute by Doppler.
Results reviewed
1 hour glucose challenge 128. Hemoglobin 10.8. Blood type O negative, antibody screen negative.
Counseling
Kick counts reviewed. Preterm labor warning signs. Small frequent meals for heartburn.
Plan
Rh immune globulin 300 mcg today. Tdap today. Ferrous sulfate 325 mg every other day. Calcium carbonate as needed for heartburn.
Next visit
2 weeks.