History of Present Illness (HPI)
History needs to include Patients age, Gravida, Para, gestational age, EDC and how EDC is determined with citation. Reason for coming to the hospital , what the patient was complaining about that brought her to come into the hospital and then admitting Diagnosis
Pathophysiology is explained in complete detail with accurate and in-depth understanding of Admitting diagnosis. and presenting signs/symptoms supported by diagnostic tests and proposed treatment plan; with APA references.
Medical History
Complete details given of other health problems (includes explanation of all relevant medical history) with full understanding as to its relation to the patient’s/ client’s present health problem(s). with APA references .Including prenatal care identify what happens in 1st trimester, 2nd trimester and 3rd trimester with APA references. inducing labs and diagnostic test, with APA references.
Surgical History
Complete details given of all surgeries patho (includes explanation of all relevant surgical history) with full understanding as to its relation to the patient’s/ client’s present health problem(s). and past surgeries. with APA references.
Social History
social issues include family outings, patient hobbies, Work
OB History
GTPAL
Need to identify previous pregnancies year , and type of delivery
Prenatal Panel
Blood Type/Rh:
GBS:
Hep B:
HIV:
Rubella:
RPR:
Chlamydia:
Gonorrhea:
HSV:
Delivery Summary
Delivery Type & Time:
Placenta Delivery Time:
Lacerations/Episiotomy:
EBL:
Hemorrhage Medications Given:
APGAR Score:1 minute____ 5 minute______
