FW: Outpatient OB Prenatal Template


In order to try to standardize how FM and WHS document prenatal records and make viewing the pregnancy information easier, we have made an outpatient OB prenatal template to go in the overview section. This will make the entire pregnancy summary available for anyone who has access to epic or care everywhere and will make a much faster view of the pregnancy when the patient presents to labor and delivery.

Instructions for overview section:
  1. Add “pregnancy” or “high risk pregnancy” to your problem list
  2. Remember to link the pregnancy problem to that specific pregnancy episode (this will allow it to drop off once the pregnancy episode is complete). Go to details under the problem and click the “link” box
  1. Use the dot phrase is .sanrprenataloverview in the overview section. This should be an overview of the plan for the entire pregnancy. The problem list is supposed to show what needs to be done for antenatal testing, etc, not act as the progress note for the visit.
  2. Update the overview section each visit

Instructions for prenatal visit progress notes:

We would still like to have a detailed progress note each visit, since this is what the preceptors see when signing notes
  1. For initial OB visits use .sanrinitialprenatal which will go through a more detailed H&P
  2. For return OB visits
    1. Option 1- You can use the pregnancy overview template in the progress note, but make sure to include the subjective information pertinent for that visit and a more detailed plan for the problems that day
    2. Option 2- Continue to use the .sanrprenatal dotphrase for a more abbreviated note

Let me know if you have any questions.


Krystal Tamura
Inpatient Medical Director, Faculty
St. Anthony North Family Medicine Residency
720-352-4874 Phone
303-430-5565 Fax
14300 Orchard Pkwy.
Westminster, CO 80023
krystaltamura@centura.org

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