Arrival times: we have gotten feedback from NHC staff that residents are often late and patients are left waiting in rooms. Understandably, sometimes things are busy with rounds and triage patients prior to coming to NHC, but at least one resident should be present at NHC at start time (8am on M/F, and 12pm on W). Ideally, only one member of the team should need to stay back and tie up loose ends. We are aware that there are definitely times when everyone is on time and there are no patients ready to be seen, but having at least one person ready to see patients will keep flow moving, and should keep everyone happy. Keep in mind that notes do not need to be finished prior to clinic (I mean, finish them if you can, but no biggie if you don’t). If the service is busy, do quick chart rounds, open and time-stamp your notes, pop in and say hi to patients, then save the notes and get to clinic.
First prenatal visit: when taking an I2, please make sure you know the details of their previous pregnancies, and that everything is documented appropriately in the ‘Form A’ tab. You should know the year, type of delivery (NSVD/VAVD/CS), how many weeks, if preterm was it spontaneous or induced, baby’s size, and complications of the pregnancy, delivery, or postpartum period. Get all the details you can on previous deliveries - if a CS, why? What was the largest baby? Any diabetes or HTN issues? If GDM were they on meds? If preeclampsia were they on mag? Did they get sent home on BP meds? Ultimately, reporting these in the I2 note can be more brief if needed (ie. “had all term vaginal deliveries, largest baby was 8lbs 5oz, no complications of pregnancy, delivery, postpartum period”). Knowing all the details of previous pregnancies allows us to determine the level of risk of the patient, and anticipate problems that could arise later, consults that need done, and extra labs or medications that might be necessary.
Clinic notes: Please see the document about “How to Chart” which outlines how you all should be documenting (as well as a second document that has a list of abbreviations to know, so you can make more concise notes). Please read it. Twice. We need our notes (each one) to be able to stand alone, so that an outside source knows everything you’re thinking in that one note. They do not need to be long and ridiculous, but in a few sentences just make sure that whoever is reading can know 1. What happened this visit 2. That you’re thinking about all the other things (ie “s/p TDaP shot, declines flu” tells us you addressed immunizations), and 3. What the plan is for the next visit. Whoever sees the patient for the subsequent visit should be able to read your one note, and get all the info they need for their visit from it. Ideally, the person who does the patient’s I2 should be the only person digging through the chart looking for history, ironing out details of past deliveries etc, and each appointment after this should be just looking at new labs or ultrasounds. This is one thing I’m going to be SUPER strict about, because this is one of the only ways that MFM and outside providers can assess our care – we are aiming for excellent notes only, so please take the extra 30 seconds needed to make your notes perfect….or else ;-)
Dating: know your rules for dating, and know how to present that patient. “26yo G3 at 29 weeks by LMP and third trimester ultrasound” doesn’t give us all the info we need. Is it a sure (they are sure of the dates) and reliable (regular periods, no pregnancies or birth control in the 3 months prior to conception) period. If not yes to both of these, we go by ultrasound dating. And when reporting the ultrasound, you should say how many weeks, rather than trimester – saying second trimester could be 14+0 or 27+6, and depending which one of those the ultrasound was done at, we have a completely different level of confidence in that dating! As well, know that we no longer use the “1 week for first trimester, 2 weeks for second trimester….etc” way of changing due dates. Acog has a new protocol based on gestational age – see under “Quick Reference Material” (and note, this table is hanging up in the NHC call room, as well as the workroom at NHC).
Drug Screens: We are going to start doing urine drug screens on ALL prenatal patients at their first visit (and this goes for FMC too). Per the new Indiana law passed 7/2019, we must also be screening patients with a standardized verbal screening tool - NHC and FMC are both using the 5 Ps (see in “Quick Reference Material”). Any positive screens (urine or verbal) need to be addressed, and it’s important that the patients know that we are testing so that we can have healthy pregnancies, and get them the help they need early. Depending on what substance is found, different steps can be taken – social work should see anyone with a positive screen, and if appropriate, patients should be referred to substance use counseling, MAT program, or even inpatient detox programs. Note that it is ILLEGAL to report someone to DCS for a positive drug screen alone - there must be other concerns about abuse or neglect in the situation. If not sure about this - ask me.
Contraceptive Planning: the patient’s plan for birth control/family planning after delivery should be discussed/confirmed and documented at EVERY visit, starting from the I2. Too often we are missing our chance for patient’s to sign their tubal paperwork because we forgot to do it, and this is a HUGE DEAL!! Women need to have a plan in place (even if that plan is natural family-planning), because this gives them some control over their bodies and when they decide to have their next baby (if they are planning this). If a patient without insurance is interested in a LARC (note – emergency Medicaid ONLY covers the delivery, and not a tubal), they can get free Nexplanon insertion at the Lafayette Family Health Clinic. As well, NHC offers free (or extremely cheap) IUD placements for uninsured patients as well (placed around 6 weeks PP, and must have a negative GC/CT). If someone with insurance wants a Nexplanon, you can refer them to the FMC for this. Any combination meds (OCPs, ring, patch) should wait to be started until 4-6 weeks postpartum, but any progestin meds (POPs, depo, Nexplanon) can be given/started/placed more or less immediately. IUDs shouldn’t be placed until 6 weeks postpartum because of the risk of perforation.
Reviewing Ultrasounds: whenever an ultrasound is ordered to check on or monitor growth, please report the percentile of EFW in the note somewhere – Parkview radiology will usually report this in their report (an exact percentile), but in the from Lutheran radiology you often won’t often get a percentile, or they will give a general percentile – if they say “25-50th” or “75th-90th” this is often not consistent with how we assign percentiles, so please calculate yourself. If Lutheran gives you an exact percentile, it’s usually around/at where we would get the same, so can usually trust. Caveat here is that sometimes they aren’t using the due date we are using, so this needs to be reviewed as well, and if they report something different, then again, calculate yourself. You can calculate this on http://perinatology.com/calculators/exbiometry.htm (google perinatology fetal biometry calculator). You plug in the gestational age at time of ultrasound, and weight in grams…easy peasy.