http://www.stritch.luc.edu/lumen/meded/obgyne/tools.pdf WebPelvic exam is a important part of the exam for female patients and important towards making various diagnoses such as yeast vulvovaginitis, bacterial vaginosis, lichen sclerosis, cancers such as cervical cancer, anal/rectal cancer, fibroids, sexually-transmitted infections (gonorrhea, chlamydia, trichomonas, syphilis, herpes and human …
Family History as a Risk Assessment Tool ACOG
WebThe date a physician or other health care professional first examined or counseled the pregnancy woman for the pregnancy. Categories: Prenatal Care and Pregnancy History 7. Total number of prenatal care visits for this pregnancy The total number of visits recorded in the record. Categories: Prenatal Care and Pregnancy History 8. WebDec 29, 2024 · Lesson 2: Clinical Staff Training: Documenting the Pregnancy (12:18 minutes) Lesson 1: Documenting the Pregnancy with Confirmation of Pregnancy (25:39 minutes) ... OB History Tab: 16. Syncing with Athenahealth: 7. Patient History Tab: 17. L&D Fax: 8. Patient Education Tab: 18. Delivery Information: 9. About Tab: purpose of data privacy act of 2012
OB/GYN MEDICAL RECORD DOCUMENTATION GUIDELINES
WebJul 12, 2024 · a signature and date on any document with updated or revised information as an attestation that it is current. Medical Students A medical student has no legal status as a provider of health care services, therefore, a medical History and Physical (H&P) conducted by a medical student would not fulfill the requirements. WebTPAL notation when documenting OB/GYN history. T- Number of term births P- Number of preterm birth (<37 weeks) A- Number of abortions L- Number of living children Refer to slide 48 for clarification. What to document regarding health and preventative care status. Last physical exam WebJan 14, 2024 · Article Medical and OB/GYN Gravidity and parity are important parts of a complete obstetric history. To put it simply: Gravidity (gravida) is the number of times a patient has been pregnant. This includes a current pregnancy Parity (para) is the number of times a patient has given birth to a viable child security credit bogalusa