General Obstetric Intake

Chief Complaint

General Obstetric Intake

Template

General Obstetric Intake ob,new,detailed,pregnancy,prenatal Obstetrics & Gynecology (ObGyn) [In narrative form, document the details surrounding the patient’s chief complaint. Include the date of the last menstrual period (LMP), details of home pregnancy tests or other confirmation methods, symptoms like nausea, vomiting, breast tenderness, fatigue, spotting, and any other concerns or questions the patient might have about the pregnancy.] [For each prior pregnancy, include the year, gestational age at delivery, type of delivery, any complications, and outcomes. Document any miscarriages and at which week of pregnancy they occurred. Include any history of infertility or assisted reproductive technology. Document VTE risk assessment, immunizations, Rh-status if known.] [Include information on menstrual history, contraceptive use, relevant sexual history, history of sexually transmitted infections, Pap smear history, and any gynecological conditions.] [Include all significant medical conditions with dates if available, such as hypertension, diabetes, thyroid disorders, etc.] [List all previous surgeries, their dates, any complications, and outcomes.] [Include significant medical conditions in first-degree relatives, especially those relevant to pregnancy, such as diabetes, hypertension, congenital abnormalities or known hereditary conditions, etc.] [Include information on tobacco use, alcohol use, illicit drug use, occupation, living situation, and marital status. Document any exposure to domestic violence.] Constitutional – [no Fever, Chills, Weight Loss, Weight Gain, Night sweats, Fatigue, or Weakness] Eyes – [no double vision, no blurry vision, wears glasses] ENT – [no Hearing loss, dizziness, runny nose, nose bleeds, nasal septum deviation, or sore throat] Integumentary – [no rashes, lesions, dry skin, or eczema] Cardiovascular – [no chest pain, heart palpitations, dizziness] Respiratory – [no shortness of breath, no cough, no wheezing] Endocrine – [No known thyroid issues, no changes to appetite, no weight change, no tiredness/lethargy] Gastrointestinal – [No nausea, vomiting, diarrhea, or constipation. No problems swallowing. No abdominal pain or bloating.] Genito Urinary – [no Dysuria, hematuria, frequency, urgency. No spotting.] Musculoskeletal – [no joint tenderness, redness or swelling] Neurological – [No headaches, no weakness, no history of seizures] Psychology – [No changes in mood, no anxiety] Hematology – [Denies easy bruising] [Document all current medications, including dosages and frequency, as well as any over-the-counter medications and supplements, including prenatal vitamins.] [Document any drug, food, or environmental allergies, including the nature of the reaction.] [Include blood pressure, heart rate, respiratory rate, temperature, weight, height, BMI] General – Appears well, no obvious discomfort ENT – [No cervical lymphadenopathy, throat normal with no erythema or exudates.] Cardiovascular – [Heart rate regular, S1S2 normal with no murmurs or added sounds, peripheral pulses easily palpable, equal and symmetric, normal capillary refill, no JVD, no carotid bruits, no central or peripheral cyanosis, no clubbing, no peripheral edema.] Respiratory – [Lungs clear to auscultation bilaterally with no wheezes or crackles, normal symmetrical chest expansion.] Skin – [No rashes, no dry skin, no skin infections] Breasts: [Normal symmetrical appearance, no erythema, skin changes or tethering, no inverted nipples. Non-tender normal breast tissue on palpation with no palpable masses. Normal axillary lymph nodes on palpation.] Abdomen – [Normal bowel sounds, abdomen soft and tender, no distension, uterus palpable] Genito Urinary – [External genitalia normal, no inguinal adenopathy, normal pelvic examination] Musculoskeletal – [No tender, swollen, warm, or erythematous joints. Normal range of motion in examined limbs, no muscle tenderness.] Neurological – [Alert and oriented in time, space and person, normal gait, strength 5/5 in upper and lower limbs, CN 2-12 grossly intact, coordination intact.] [Include results of any pertinent laboratory tests (e.g., urine pregnancy test), imaging studies (e.g., dating ultrasound), or other diagnostic evaluations.] [Summarize the clinical impression based on the history and exam, e.g., confirmed intrauterine pregnancy, first trimester] [List problems/diagnoses identified, e.g., early pregnancy, nausea] [If indicated, include potential diagnoses relevant to the clinical presentation] Orders and Referrals: [Include laboratory tests (e.g., blood type, Rh factor, complete blood count, HIV screening, etc.), obstetric ultrasounds, referrals to specialists if needed] Treatments: [Include prenatal vitamins, management of common symptoms like nausea, other treatments] Patient Education: [Discuss educational points provided to the patient, such as lifestyle modifications, dietary recommendations, avoidance of certain substances, importance of prenatal care visits, danger signs in pregnancy] Follow Up: [Include follow-up appointments, monitoring plans, e.g., next prenatal visit in 4 weeks]