OB CHART REVIEW

Performed By: [text name="variable_34" default=""] on [date name="variable_35" default=""]
Patient Name: [text name="variable_36" default=""] 
  Current GA: [text name="variable_37" default=""].[text name="variable_38" default=""] wks
Continuity Providers: [text name="variable_39" default=""]
----------------------------------------------------

[text name="variable_44" default=""]yo G[text name="variable_40" default=""] P[text name="variable_41" default=""]
EDD: [date name="variable_42" default=""] Established by: [select name="variable_43" value="LMP|US"]
Documented in Chart: [checkbox name=""variable_1" value="Yes +1|No -1"]

Problem List/Care Plan Reviewed & Updated
- Encounter for Supervision of Normal/Abnormal/First/Subsequent Pregnancy
- Pregnancy & Non-Pregnancy Related Problems documented in Care Plan
Documented: [checkbox name="variable_2" value="Yes +1|No -1"]

20 Week Anatomy Scan Ordered: [checkbox name="variable_3" value="Yes +1|No -1"]
Anatomy Scan documented in the Care Plan: [checkbox name="variable_4" value="Yes +1|No -1"]

Does patient require additional management? i.e. Antenatal Testing, Growth Scan, MFM referral, Induction scheduled 
**[textarea name="variable_1" default=""]**
[checkbox name="variable_5" value="-1 Applicable & Not Done or Not documented"]

LAB RESULTS & TASKS BY TRIMESTER
First Trimester:
[checklist name="variable_6" value="Complete PE Performed at Intake|Discussed Genetic Screening|Depression Screen|ABO|Rh Status|Antibody Screen|RPR|HIV|Rubella|Hgb|HepBsAg|Hep C|Urine Cx|GC/CT"]Pap Smear: [checkbox name="variable_7" value="Yes|No -1|N/A"]
If GC/CT positive, was a TOC performed 4wk later? [checkbox name="variable_8" value="Yes|No -1|N/A"]
Early 1hr GTT: [checkbox name="variable_9" value="Yes|No -1|N/A"]
TSH: [checkbox name="variable_10" value="Yes|No -1|N/A"]
UDS: [checkbox name="variable_11" value="Yes|No -1|N/A"]

Second Trimester:
1hr GTT: [checkbox name="variable_12" value="Yes +1|No -1"]
3hr GTT: [checkbox name="variable_13" value="Yes|No -1|N/A"]
Rhogam Given at 28 weeks: [checkbox name="variable_14" value="Yes|No -1|N/A"]

Third Trimester:
[checklist name="variable_15" value="Repeat H/H|Repeat RPR"]Repeat GC/CT if high risk: [checkbox name="variable_16" value="Yes|No -1|N/A"]
GBS: [checkbox name="variable_17" value="Yes|No -1|Not Time"]
Confirm Presentation @ 36 wk: [checkbox name="variable_18" value="Yes|No -1|Not Time"]

Immunizations
Flu Vaccine: [checkbox name="variable_19" value="Yes|No -1|N/A or Pt declined"]
Tdap at 27-36 weeks: [checkbox name="variable_20" value="Yes +1|No -1"]

Delivery Plan
TOLAC Candidate? [checkbox name="variable_21" value="Yes & Documented|Yes, not documented -1|No"]
** If yes, referral for TOLAC made? [checkbox name="variable_22" value="Yes|No -1|N/A or Pt declined"]
Contraception Plan Discussed: [checkbox name="variable_23" value="Yes +1|No -1"]
** If sterilization desired, has a consent been signed? [checkbox name="variable_24" value="Yes|No -1|N/A"]
Pediatrician: [checkbox name="variable_25" value="Yes +1|No"]
Analgesia Plan: [checkbox name="variable_26" value="Yes +1|No"]

BMI Target Weight Gain
[checklist name="variable_27" value="<18.5 (28-40 lbs)|18.5 - 24.9 (25-35 lbs)|25 - 29.9 (15-25 lbs)|>30 (11-20 lbs)"][checkbox name="variable_1" value="Discussed +1|Not Discussed"]On target for appropriate weight gain? [checkbox name="variable_29" value="Yes|No, addressed|No, not addressed -1"]

Fundal Heights: [checkbox name="variable_30" value="Normal|Abnormal, addressed|Abnormal, not addressed -1"]
Blood Pressures: [checkbox name="variable_31" value="Normal|Abnormal, addressed|Abnormal, not addressed -1"]

Score: [text name="variable_1" default=""]/25

Summary of Actions to be Completed by Resident:
[textarea name="variable_33" default=""]
Performed By: on
Patient Name:
Current GA: . wks
Continuity Providers:
----------------------------------------------------

yo G P
EDD: Established by:
Documented in Chart:

Problem List/Care Plan Reviewed & Updated
- Encounter for Supervision of Normal/Abnormal/First/Subsequent Pregnancy
- Pregnancy & Non-Pregnancy Related Problems documented in Care Plan
Documented:

20 Week Anatomy Scan Ordered:
Anatomy Scan documented in the Care Plan:

Does patient require additional management? i.e. Antenatal Testing, Growth Scan, MFM referral, Induction scheduled
****


LAB RESULTS & TASKS BY TRIMESTER
First Trimester:
Pap Smear:
If GC/CT positive, was a TOC performed 4wk later?
Early 1hr GTT:
TSH:
UDS:

Second Trimester:
1hr GTT:
3hr GTT:
Rhogam Given at 28 weeks:

Third Trimester:
Repeat GC/CT if high risk:
GBS:
Confirm Presentation @ 36 wk:

Immunizations
Flu Vaccine:
Tdap at 27-36 weeks:

Delivery Plan
TOLAC Candidate?
** If yes, referral for TOLAC made?
Contraception Plan Discussed:
** If sterilization desired, has a consent been signed?
Pediatrician:
Analgesia Plan:

BMI Target Weight Gain
On target for appropriate weight gain?

Fundal Heights:
Blood Pressures:

Score: /25

Summary of Actions to be Completed by Resident:

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.76, 45 form elements, 175 boilerplate words, 9 text boxes, 2 text areas, 2 dates, 28 checkboxes, 3 check lists, 1 drop downs, 106 total clicks
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