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Prenatal Visit Note Pregnancy Dating - Gravida/para, EDD source (LMP/US), current gestational age, and singleton vs multiple gestation. Interval Maternal History - Symptoms: vaginal bleeding, leaking fluid, contractions/cramping, headache, visual changes, RUQ/epigastric pain, edema, dysuria, fever, decreased fetal movement. - Medication/supplement adherence (prenatal vitamin, iron, aspirin if prescribed), substance exposure, and social stressors/IPV screening if performed. - Interval ED visits, illnesses, or hospitalizations. Fetal Assessment - Fetal movement report; FHR (method/rate) and fundal height if measured. - Presentation if assessed; NST/BPP/ultrasound results reviewed today. Exam / Maternal Data - Weight, BP, urine dip if performed, edema, and relevant exam findings. - Cervical exam only if indicated and performed. Labs / Screening Reviewed - Prenatal labs, aneuploidy/genetic screening, GDM testing, Rh/antibody, GBS, anemia studies, and imaging as discussed. - Vaccinations (Tdap, influenza, RSV, COVID) status if addressed. Assessment - Intrauterine pregnancy at ___ weeks with prenatal course summary (routine vs complicated). - Active obstetric or maternal problems. Plan - Anticipatory guidance for gestational age; warning signs reviewed. - Orders: labs, ultrasound, antenatal testing, referrals (MFM, anesthesia, lactation). - Medications/supplements and follow-up interval.
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Illustrative excerpt of how a visit can land in this structure. Not a real patient record—review and edit every note before signing.
Pregnancy Dating G2P1001, EDD by first-trimester US. Currently 28w2d singleton. Interval History Good fetal movement. No bleeding, leaking, contractions, headache, or visual changes. Taking prenatal vitamin and low-dose aspirin for history of preeclampsia. Denies tobacco/alcohol. Fetal Assessment FHR 142 by Doppler. Fundal height 28 cm. Anatomy US previously normal. Exam / Data Weight +0.8 lb; BP 112/68; urine neg protein/glucose. Mild trace ankle edema. Labs / Screening 1-hour GCT today 118 (normal). Tdap given today. Rh negative; RhIg planned at 28 weeks—administered after visit counseling. Assessment 28w2d IUP, prenatal course appropriate for gestational age. History of preeclampsia—on ASA prophylaxis. Plan Continue prenatal vitamin and ASA 81 mg. RhIg given. Kick-count education reinforced. RTC in 2 weeks; earlier for bleeding, fluid leak, severe headache, or decreased fetal movement.
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