FP Clinic OB Chart Standard Operating Procedure

FP Clinic OB Chart SOP

* This is intended to standardize the information that is in NOB/ROB charts as well as the way the information is presented. This is the way that should be from here on out.

1. Use obstetrics view

2. Ensure the EDD maintenance is UTD and ALL ULTRASOUNDS ARE INCLUDED

· Click plus sign in R corner

· Method= Ultrasound

· Date of method= Day US was performed

· EGA= Estimated gestational age from the US performed

· Comments= Enter relevant info (CRP/final EDD for FTUS, Anatomy/placenta/Hadlock for anatomy scan)

3. Use dot phrases for each relevant box

· Subj/HPI: “…nobHPISHIELDS, “…robhpiSHIELDS”

· ROS: “…obrosSHIELDS”

· Obj/PE: “…peobSHIELDS” (includes spot for dop tones, fundal height, and vertex US)

· A/P: “…rob16-18planSHIELDS” “…rob20-22planSHIELDS”, etc.

**The bonus of these dot phrases is it clues you in to what needs to be done at that appointment if you forget.

4. ENSURE ALL NOTES INCLUDE THE FOLLOWING PRIOR TO SIGNING:

ALL Notes:

- Updated EDD maintenance with all ultrasounds included (especially FTUS!)

- OB problem list annotated in HPI- updated with issues and current plans for each

- OB Problem list with ICD 10 codes updated and marked “chronic” (so it follows the pregnancy)

- OB LABS- Need to be updated with current results (copy and paste from prior chart)

- Label the note ROB/NOB and WGA (ie. “ROB 16+2”)

For NOB Notes Specifically:

- Include ASA/Pre-E risk assessment and start at 12 weeks if indicated, add to problem list

*This assessment is in NOB HPI dot phrase

- Include Dating US in physical exam to include what you saw, CRL, and FINAL EDD

*This assessment is in NOB HPI dot phrase

5. Coding

0500F(initial prenatal care visit)

0502F(Subsequent Prenatal Care Visit)

76815 (OB US, Limited fetus(s)

Code “Uncomplicated Pregnancy in primigravida/multigravida” Z34.00/Z34.80 (or Complicated preg.)

Code weeks gestation “__ weeks gestation” Z3A.XX

Code all problems in pregnancy (anemia, varicella NI, GDMA1, Breech, prior cesarean, etc.)