Assessment & Plan Elements
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[comment memo="All visits"][checkbox name="BP" value="-Blood pressure reviewed."][conditional field="BP" condition="(BP).is('-Blood pressure reviewed.')"] [select value="Appropriate, no concern for hypertensive d/o of pregnancy.|elevated."] [text size="50"]
[/conditional][checkbox value="-Breastfeeding education provided.
"][checkbox value="-Exercise during pregnancy discussed.
"][checkbox memo="if May-Oct" name="flu" value="-Flu vaccine discussed."][conditional field="flu" condition="(flu).is('-Flu vaccine discussed.')"] Patient [select value="to vaccinate once vaccine available.|to receive vaccination today.|already vaccinated.|declined"].
[/conditional][checkbox memo="NOB (10-12wk) Items" name="NOB" value=""][conditional field="NOB" condition="(NOB).is('')"][checkbox memo="confirmed dates" name="dates" value=""][/conditional][conditional field="dates" condition="(dates).is('')"][select value="EDD by LMP c/b 1st tri u/s.|EDD by 1st tri u/s, disconcordant from LMP."]
[/conditional][conditional field="NOB" condition="(NOB).is('')"][checkbox value="-Prenatal history/record reviewed.
"][checkbox value="-Oral health assessed.
"][checkbox value="-Patient's PNV use reviewed.
"][checkbox name="NOB1" value="-Weight gain goals reviewed."][/conditional][conditional field="NOB1" condition="(NOB1).is('-Weight gain goals reviewed.')"] Patient's pre-pregnancy BMI category is [select name="BMI" value="|under 18.5|18.5-24.9|25-29.9|over 30"] kg/m2[/conditional][conditional field="BMI" condition="(BMI).is('under 18.5')"] so discussed weight gain goal of 28-40lbs with 1-1.3 lbs/wk in 2nd/3rd trimesters.
[/conditional][conditional field="BMI" condition="(BMI).is('18.5-24.9')"] so discussed weight gain goal of 25-35lbs with 0.8-1 lbs/wk in 2nd/3rd trimesters.
[/conditional][conditional field="BMI" condition="(BMI).is('25-29.9')"] so discussed weight gain goal of 15-25lbs with 0.5-0.7 lbs/wk in 2nd/3rd trimesters.
[/conditional][conditional field="BMI" condition="(BMI).is('over 30')"] so discussed weight gain goal of 11-20lbs with 0.4-0.6 lbs/wk in 2nd/3rd trimesters.
[/conditional][conditional field="NOB" condition="(NOB).is('')"][checkbox name="gene" value="-Genetic screening discussed. "][/conditional][conditional field="gene" condition="(gene).is('-Genetic screening discussed. ')"]Patient opted for [select value="sequential screen 11w-13w6d|prenatal risk screen 15w3d-20w6d|no testing"].
[/conditional][conditional field="NOB" condition="(NOB).is('')"][checkbox name="CF" value="-CF screening discussed."][/conditional][conditional field="CF" condition="(CF).is('-CF screening discussed.')"] [select value="CF test ordered.|Patient sent to class at MFM."]
[/conditional][conditional field="NOB" condition="(NOB).is('')"][select value="-GC/Chlamydia endocervical swab obtained and sent to lab.
|-Reviewed recent GC/Chlamydia results which were normal.
|-GC/Chlamydia urine test ordered.
"][checkbox memo="if indicated" value="-Pelvic and bimanual exam indicated/performed.
"][checkbox memo="if indicated" value="-PAP smear performed and sent to lab.
"][checkbox memo="if sx or h/o preterm delivery" value="-Wet mount obtained and sent for analysis.
"][/conditional][conditional field="NOB" condition="(NOB).is('')"][checkbox memo="Early 1hr glucose screen indicated? (BMI>30 -or- 1st deg relative DM -or- h/o GDM -or- h/o macrosomia >4kg" name="1hr" value=""][/conditional][conditional field="1hr" condition="(1hr).is('')"]-Patient at increased risk of GDM so early 1hr prenatal glucose screen ordered.
[/conditional][conditional field="NOB" condition="(NOB).is('')"][checkbox value="-Anatomy scan U/S ordered with plan to be done at 18-22wks GA.
"][checkbox memo="17-OH progesterone 16-36wk GA indicated?" name="17OH" value=""][/conditional][conditional field="17OH" condition="(17OH).is('')"]-Due to her elevated risk of unexplained spontaneous preterm birth, recommended to patient weekly 17-OH Progesterone injections at 16-36wks GA. Patient after discussing risks/benefits [select value="acknowledged understanding and accepted|declined this"].
[/conditional][conditional field="NOB" condition="(NOB).is('')"][checkbox memo="select for add'l comments" name="NOB2" value=""][/conditional][conditional field="NOB2" condition="(NOB2).is('')"][textarea]
[/conditional][checkbox memo="16-20wk ROB Items" name="16-20" value=""][conditional field="16-20" condition="(16-20).is('')"][checkbox memo="if no 1st tri screen was offered name="quad" value="-Discussed quad screen with patient."][/conditional][conditional field="quad" condition="(quad).is('-Discussed quad screen with patient.')"] After discussion of risks/benefits, [select value="patient declined|patient accepted and test ordered"].
[/conditional][conditional field="16-20" condition="(16-20).is('')"][checkbox value="-Verified that patient has 18-22wk anatomy scan U/S ordered and scheduled.
"][checkbox name="wt1" value="-Reviewed current weight gain and goal."][/conditional][conditional field="wt1" condition="(wt1).is('-Reviewed current weight gain and goal.')"] Based on a weight gain goal of [select value="28-40lbs, 1-1.3 lbs/wk in 2nd/3rd tri|25-35lbs, 0.8-1 lbs/wk in 2nd/3rd tri|15-25lbs, 0.5-0.7 lbs/wk in 2nd/3rd tri|11-20lbs with 0.4-0.6 lbs/wk in 2nd/3rd tri"], patient's current trajectory is [select value="satisfactory|concerning for poor wt gain|concerning for excess wt gain"]. Patient [select value="encouraged to continue her healthy eating habits|counseled on- |referred to- "][text size="50"].
[/conditional][conditional field="16-20" condition="(16-20).is('')"][checkbox value="-Discussed with patient about going to L&D after 20wks GA for acute OB issues like vaginal bleeding, trauma, cramping, etc.
"][checkbox memo="if indicated" value="-17-OH progesterone treatment started d/t patient's increased risk of unexplained spontaneous preterm delivery."][checkbox memo="select for add'l comments" name="16-20A" value=""][/conditional][conditional field="16-20A" condition="(16-20A).is('')"][textarea]
[/conditional][checkbox memo="24-28wk ROB Items" name="24-28" value=""][conditional field="24-28" condition="(24-28).is('')"]
[/conditional][checkbox memo="29-32wk ROB Items" name="29-32" value=""][conditional field="29-32" condition="(29-32).is('')"]
[/conditional][checkbox memo="35-37wk ROB Items" name="35-37" value=""][conditional field="35-37" condition="(35-37).is('')"]
[/conditional][checkbox memo="38-41wk ROB Items" name="38-41" value=""][conditional field="38-41" condition="(38-41).is('')"]
[/conditional]
All visits if May-Oct NOB (10-12wk) Items 16-20wk ROB Items 24-28wk ROB Items 29-32wk ROB Items 35-37wk ROB Items 38-41wk ROB Items
Result - Copy and paste this output: