OB/GYN · Templates

OB/GYN prenatal visit template

Use this prenatal visit template in Wavo for antenatal encounters where gestational dating, maternal symptoms, fetal status, counseling, and next labs/imaging need a consistent structure.

Template content

Copy or download, then paste into Wavo under My Templates.

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.

When to use this template

What makes the structure useful, and which visits it fits best.

Why this template works

Structural advantages for real documentation

Best for

Visit types and clinicians who use this format

  • Keeps GA, fetal assessment, and maternal warning signs in predictable sections.
  • Supports routine prenatal flow plus space for high-risk concerns.
  • Documents counseling and screening without burying the plan.
  • Easy to customize for midwifery-collaborative or physician OB clinics.
  • 1Routine prenatal return visits
  • 2High-risk obstetric clinic follow-ups
  • 3Post-dating and third-trimester surveillance visits

Example output shape

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.

How Wavo automates this

What the product actually does with your template.

1. Add the template

Paste this content into My Templates, or start from a specialty-generated template and edit the sections.

2. Record or dictate

Capture the encounter with ambient recording or dictation. Wavo structures the note using your template.

3. Review and sign

Edit with Smart Transform if needed, then export or copy into your EHR. You stay responsible for the final note.

Put this template to work on your next visit

Start free, paste the template, and see how Wavo documents in your structure.