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MEDICAL RECORD PRENATAL AND PREGNANCY - PDF

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MEDICAL RECORD PRENATAL AND PREGNANCY - PDF Powered By Docstoc
					PREVIOUS EDITION IS NOT USABLE                                                                                                                        NSN 7540-00-634-4276
                                                                                                                                                      DATE
    MEDICAL RECORD                                                     PRENATAL AND PREGNANCY
                                                                                                                                                        06/16/2013
                                                                          PATIENT INFORMATION
LAST NAME                                                                                 FIRST NAME                                                          MIDDLE INITIAL
Stacey                                                                                    Hockett
STREET ADDRESS                                                                            CITY                                                STATE     ZIP CODE
601 North Lake Shore Drive                                                                Chicago                                                IL     60025
        TELEPHONE (Home)                             TELEPHONE (Work)                     ID NUMBER                 DAY OF BIRTH (Month, Day, Year)     AGE
AREA CODE       NUMBER                 AREA CODE       NUMBER                 EXT.
312             555-5555                                                                                                                                41
                                         RACE                                             EDUCATION (Last grade                               OCCUPATION
                                                                                          completed)
     WHITE           HISPANIC WHITE              AMERICAN INDIAN/ALASKA NATIVE                                                 HOMEMAKER
                                                                                                                                                 OUTSIDE WORK
     BLACK           HISPANIC BLACK              ASIAN/PACIFIC ISLANDER                                                        STUDENT
                                   MARITAL STATUS                                                                           TYPE OF WORK
     SINGLE                      MARRIED
                                                                         WIDOWED
     DIVORCED                    SEPARATED                                                EMERGENCY CONTACT                                       TELEPHONE
                             HUSBAND/FATHER OF BABY                                                                                  AREA CODE    NUMBER
NAME                                                             TELEPHONE
                                                  AREA CODE        NUMBER                 NEWBORN'S PHYSICIAN                        REFERRED BY
Gregory
FINAL ESTIMATED DELIVERY DATE                HOSPITAL OF DELIVERY                         PRIMARY PROVIDER/GROUP                     MEDICAID NUMBER/INSURANCE
02/08/2014
                                                                        NUMBER OF PREGNANCIES
TOTAL                  FULL TERM         PREMATURE ABORTIONS INDUCTED ABORTIONS SPONTANEOUS                          ECTOPICS        MULTIPLE BIRTHS     LIVING
4                      3                 0               0                           0                               0               0                   3
                                                                      PAST PREGNANCIES (LAST SIX)
                              LENGTH                                                                                             PRETERM
     DATE          GA                          BIRTH         SEX          TYPE                                 PLACE OF           LABOR             COMMENTS/
                                 OF                                                      ANESTHESIA                              DELIVERY
    (MO/YR)       WEEKS                       WEIGHT                    DELIVERY                               DELIVERY                            COMPLICATIONS
                               LABOR                         F    M                                                              YES NO
    04/2001           41          16           7# 12                     Vaginal           Epidural          Brookside MC                               Robert
    07/2003           40           5           7#10                      Vaginal           Epidural          Brookside MC                                 Lori
    01/2006           39           4            8#0                      Vaginal           Epidural          Brookside MC                              Elizabeth



                                                                          MENSTRUAL HISTORY
                LAST MENSTRUAL PERIOD                                     MENSES                               FREQUENCY                              MENARCHE
     DEFINITE          APPROXIMATE (MONTH KNOWN)                 MONTHLY      PRIOR (Date)        Q (Days)             ON BCP AT         AGE ONSET       hCG + (Date)
     UNKNOWN           NORMAL AMOUNT/DURATION                      YES                                                 CONCEPT
     FINAL:   05/04/2013                                           NO                                                 YES         NO     9               06/05/2013
                                                          SYMPTOMS SINCE LAST MENSTRUAL PERIOD
DESCRIBE ALL SYMPTOMS
Extreme fatigue


RELATIONSHIP TO SPONSOR                                                              SPONSOR'S NAME                                              SPONSOR'S ID NUMBER
                                                                                                                                                 (SSN or Other)
                                       LAST                                               FIRST                                          MI


DEPART./SERVICE                                              HOSPITAL OR MEDICAL FACILITY                            RECORDS MAINTAINED AT


PATIENT'S IDENTIFICATION (For typed or written entries, give: Name -- last, first, middle; ID No.            REGISTER NO.                             WARD NO.
                         or SSN; Sex)


                                                                                                                          PRENATAL AND PREGNANCY
                                                                                                                               Medical Record

                                                                                                                              STANDARD FORM 533 (REV. 12-1999)
                                                                                                                         Prescribed by GSA/ICMR FMR (41 CFR) 101-11.203
                                                                                                                                    NSN 7540-00-634-4276
LAST NAME                                    FIRST NAME                                            MIDDLE INITIAL     ID NUMBER
Stacey                                       Hockett
                                                         PAST MEDICAL HISTORY
                         O NEG        DETAIL POSITIVE REMARKS                                                O NEG      DETAIL POSITIVE REMARKS
         ITEM                                                              ITEM
                         + POS        (Include Date and Treatment)                                           + POS      (Include Date and Treatment)
                                                                   PULMONARY
DIABETES
                            0                                      (TB, ASTHMA)                                0
HYPERTENSION                                                               ALLERGIES (DRUGS)
                            0                                                                                  0
HEART DISEASE                                                              BREAST
                            0                                                                                  0
AUTOIMMUNE                                                                 HISTORY OF
DISORDER                    0                                              ABNORMAL PAP                        0
                                                                           UTERINE ANOMALY/
KIDNEY DISEASE/UTI
                            0                                              DES                                 0
PSYCHIATRIC                                                                INFERTILITY
                            0                                                                                  0
NEUROLOGIC/                                                                RELEVANT FAMILY
EPILEPSY                    0                                              HISTORY                             0
HEPATITIS/LIVER
DISEASE                     0
                                                                           GYN SURGERY
VARICOSITIES/
PHLEBITIS                   0                                                                                  0
THYROID
                                                                           OPERATIONS/HOS-
DYSFUNCTION                 0                                                                                        2001 - Childbirth
                                                                           PITALIZATIONS
TRAUMA/DOMESTIC
                                                                           (Year and Reason)
                                                                                                                     2003 - Childbirth
VIOLENCE                    0                                                                                  +     2006 - Childbirth
HISTORY OF BLOOD                                                           ANESTHETIC
TRANSFUSION                 0                                              COMPLICATIONS                       0
D (RH) SENSITIZED                                                          OTHER (Specify)
                            0
             USE OF TOBACCO                                    USE OF ALCOHOL                                         USE OF STREET DRUGS
     NUMBER OF CIGARETTES         NO. OF           NUMBER OF DRINKS PER DAY      NO. OF YEARS                      AMOUNT PER DAY        NO. OF YEARS USE
           PER DAY                YEARS                                          DRINKING
                                              PRIOR TO         NOW                                       PRIOR TO         NOW
                                  SMOKED
PRIOR TO PREGNANCY NOW                        PREGNANCY                                                  PREGNANCY

0                    0            0           0                0                 0                       0                0              0
COMMENTS/COUNSELING




                                           GENETICS SCREENING/TERATOLOGY COUNSELING
                                             (Includes Patient, Baby's Father, or anyone in Either Family)
                          ITEM                               YES NO                                           ITEM                             YES NO
PATIENT'S AGE IS GREATER THAN 35 YEARS
                                                                           MENTAL RETARDATION/AUTISM
THALASSEMIA (ITALIAN, GREEK, MEDITERRANEAN, OR ASIAN
BACKGROUND (MCV IS LESS THAN 80)                                           IF YES, WAS PERSON TESTED FOR FRAGILE X
NEURAL TUBE DEFECT (MENINGOMYELOCELE, SPINA BIFIDA, OR
ANENCEPHALY)                                                               OTHER INHERITED GENETIC OR CHROMOSOMAL DISORDER
CONGENITAL HEART DEFECT                                                    MATERIAL METABOLIC DISORDER *E.G., INSULIN-DEPENDENT
DOWN SYNDROME                                                              DIABETES, PKU)
TAY-SACHS (E.G., JEWISH, CAJUN, FRENCH CANADIAN)                           PATIENT OR BABY'S FATHER HAD A CHILD WITH BIRTH DEFECTS
SICKLE CELL DISEASE OR TRAIT (AFRICAN)                                     NOT LISTED ABOVE

HEMOPHILIA                                                                 MEDICATIONS/STREET DRUGS/ALCOHOL SINCE LAST MENSTRUAL
MUSCULAR DYSTROPHY                                                         PERIOD
CYSTIC FIBROSIS                                                            IF YES, LIST AGENT(S)
HUNTINGTON CHOREA
RECURRENT PREGNANCY LOSS OR A STILLBIRTH                                   ANY OTHER
COMMENTS/COUNSELING
Wants testing for Down's Syndrome
                                                                                                             STANDARD FORM 533 (REV. 12-1999) PAGE 2
                                                                                                                                                  NSN 7540-00-634-4276
                                                                            INFECTION HISTORY
                                  ITEM                                      YES NO                                         ITEM                               YES NO
HIGH RISK HEPATITIS B/IMMUNIZED                                                           RASH OR VIRAL ILLNESS SINCE LAST MENSTRUAL PERIOD
LIVE WITH SOMEONE WITH TB                                                                 HISTORY OF STD, GC, CHLAMYDIA, HPV, SYPHILIS
EXPOSED TO TB                                                                             OTHER
PATIENT OR PARTNER HAS HISTORY OF GENITAL HERPES
COMMENTS


DRUG ALLERGY                                                  RELIGIOUS/CULTURAL CONSIDERATIONS                        ANESTHESIA CONSULT PLANNED
None                                                          Episcopal                                                                  YES                  NO

INTERVIEWER'S SIGNATURE

                                                                   INITIAL PHYSICAL EXAMINATION
EXAM DATE                PRE-PREGNANCY WEIGHT                 PRESENT WEIGHT                       HEIGHT                           BP
06/16/2013               147                                  144                                  5'6"                             110/72
                                                                    CHECK ONE
                           ITEM                                                                     ITEM                                 RESULT
                                                               NORMAL       ABNORMAL
HEENT                                                                                     VULVA                         NORMAL      CONDYLOMA                LESIONS
FUNDI                                                                                     VAGINA                        NORMAL      INFLAMMATION             DISCHARGE
TEETH                                                                                     CERVIX                        NORMAL      INFLAMMATION             LESIONS
THYROID                                                                                                            NO. OF WEEKS:
                                                                                          UTERUS SIZE                                                        FIBROIDS
BREASTS                                                                                                            6
LUNGS                                                                                     ADNEXA                        NORMAL      MASS
HEART                                                                                     DIAGONAL                                                     CM
                                                                                                                        REACHED     NO
ABDOMEN                                                                                   CONJUGATE

EXTREMITIES                                                                               SPINES                        AVERAGE     PROMINENT                BLUNT
SKIN                                                                                      SACRUM                        CONCAVE     STRAIGHT                 ANTERIOR
LYMPH NODES                                                                               SUBPUBIC ARCH                 NORMAL      WIDE                     NARROW
RECTUM                                                                                    GYNECOID PELVIC TYPE          YES         NO
COMMENTS (List type and explain abnormality)




                                                                                                                       MEDICATION LIST
               PROBLEMS                                       PLANS
                                                                                                            TYPE                   START DATE            STOP DATE
Age 41                                      BUN, CVS                                      PNVs                                     06/10/2013



                                                                  ESTIMATED DELIVERY DATE (EDD)
                                                                         CONFIRMATION
           ACTION                         DATE                      WEEKS                       EDD            INITIAL EDD
LMP                                  05/04/2013                                           02/08/2014           02/08/2014
INITIAL EXAM                         06/16/2013                        6                  02/08/2014           INITIALED BY
ULTRASOUND
                                                                            18-20 WEEK UPDATE
                  ACTION                          ORIG. DATE               WEEKS                NEW DATE       FINAL EDD

QUICKENING
FUNDAL HT. AT UMBIL.
                                                                                                               INITIALED BY
FHT W/FETOSCOPE
ULTRASOUND
PATIENT'S IDENTIFICATION (For typed or written entries, give: Name -- last, first, middle; ID               REGISTER NO.                          WARD NO.
                         No. or SSN; Sex; Date of Birth; Rank/Grade)




                                                                                                                       STANDARD FORM 533 (REV. 12-1999) PAGE 3
                                                                                                                                                                               NSN 7540-00-634-4276
LAST NAME                                                                      FIRST NAME                                             MIDDLE INITIAL ID NUMBER
Stacey                                                                         Hockett
                                                                                                           VISITS
                                                                         PRETERM LABOR
             WEEKS GEST.




                                                                                            CERVIX EXAM
                                         PRESENTATION
                           HEIGHT (CM)




                                                                                                                                                   MENT (Date)
             (BEST EST.)




                                                              MOVEMENT
                                                                         SIGNS/SYMPTOMS                   BLOOD                        URINE




                                                                                                                                                                 PROVIDER
                                                                                            (DIL./EFF./




                                                                                                                                                   APPOINT-
  DATE                                                                                                    PRES-                      (GLUCOSE/                                     COMMENTS
                           FUNDAL




                                                                                                                            WEIGHT
                                                                                                                    EDEMA




                                                                                                                                                                 (Initials)
                                                              FETAL
                                                                                                           SURE                       ALBUMIN)




                                                                                                                                                   NEXT
                                                                         PRESENT ABSENT




                                                                                            STA.)
                                                        FHR

06/16/2013      6                                                                                         110/72            144         -/-      07/03/2013                   NOB Age 41

07/01/2013      8                                                                                         114/76            144         -/-                                   Spotting, no FHTs




PROBLEMS                                                                                                     COMMENTS
06/16/2013: Age 41                                                                                           06/16/2013: Age 41, wants Down's testing. Briefly reviewed
                                                                                                             options. Considering BUN at 10 wks, CVS at 11 or 12. Return
                                                                                                             in 2-3 weeks for final counseling.
                                                                                                             07/01/2013: Spotting. Just sent over from ultrasound. 7-wk size,
                                                                                                             no FHTs.




                                                                                                                                              STANDARD FORM 533 (REV. 12-1999) PAGE 4
                                                                                                                                              NSN 7540-00-634-4276

                                                                        LABORATORY AND EDUCATION

                                   TYPE               DATE                        RESULT                         REVIEWED        COMMENTS/ADDITIONAL LAB
                                                                       A                     B
                           BLOOD TYPE
                                                    06/18/2013         AB                    O

                           D (RH) TYPE
                                                    06/18/2013   Pos
                                                                       NORMAL                OTHER
                           PAP TEST
                                                    06/18/2013         ABNORMAL
                                                                       POSITIVE
                           HIV COUNSELING/TESTING                                              DECLINED
                                                    06/18/2013         NEGATIVE
     INITIAL LABS




                           ANTIBODY SCREEN
                                                    06/18/2013   Neg
                           RUBELLA
                                                    06/18/2013   Neg
                           VDRL
                                                    06/18/2013   Neg
                                                                 PERCENTAGE             G/DL
                           HCT/HGB
                                                    06/18/2013   34.8                   11.9
                           URINE CULTURE/SCREEN
                                                    06/18/2013   Neg
                           HB s AG
                                                    06/18/2013   Neg
                                                                       AA         AS           SS         AC
                           HGB ELETROPHORESIS
                                                                       SC         AF           TA2

                           PPD
     OPTIONAL LABS




                           CHLAMYDIA
                                                    06/18/2013   Neg
                           GC
                                                    06/18/2013   Neg
                           TAY-SACHS


                           OTHER


                           ULTRASOUND
(When indicated/elected)
  8-18 WEEK LABS




                           MSAFP/MULTIPLE
                           MARKERS

                           AMNIO/CVS

                                                                       46, XX           OTHER
                           KARYOTYPE
                                                                       46, XY

                           AMNIOTIC FLUID (AFP)                        NORMAL            ABNORMAL

    PATIENT'S IDENTIFICATION (For typed or written entries, give: Name -- last, first, middle; ID No.          REGISTER NO.                   WARD NO.
                             or SSN; Sex; Rank/Grade)




                                                                                                                         STANDARD FORM 533 (REV. 12-1999) PAGE 5
                                                                                                                                NSN 7540-00-634-4276
  LAST NAME                                          FIRST NAME                                   MIDDLE INITIAL ID NUMBER

  Stacey                                             Hockett
                            TYPE             DATE                    RESULT                   REVIEWED           COMMENTS/ADDITIONAL LAB
                                                       PERCENTAGE       G/DL
                  HCT/HGB
24-28 WEEK LABS




                                                       1 HOUR
                  DIABETES SCREEN

                                                           FBS                 1 HOUR
                  GTT (If screen abnormal)
                                                           2 HOUR              3 HOUR

                  D (RH) ANTIBODY SCREEN

                  D IMMUNE GLOBULIN (RHG)              SIGNATURE
                  GIVEN (28 WEEKS)
                                                       PERCENTAGE       G/DL
                  HCT/HGB (Recommended)


                  ULTRASOUND
32-36 WEEK LABS




                  VDRL


                  GC


                  CHLAMYDIA

                  GROUP B STREP (35-37
                  WEEKS)

                                                                    PLANS/EDUCATION
                            TYPE                    COMMENTS                               TYPE                              COMMENTS
                  COUNSELED                                                       NEWBORN CAR SEAT


                  ANESTHESIA PLANS                                                POSTPARTUM BIRTH CONTROL

                  TOXOPLASMOSIS                                                   ENVIRONMENTAL/WORK
                  PRECAUTIONS (CATS/RAW                                           HAZARDS
                  MEAT)

                  CHILDBIRTH CLASSES                                              TUBAL STERILIZATION


                  PHYSICAL/SEXUAL ACTIVITY                                        VBAC COUNSELING


                  LABOR SIGNS                                                     CIRCUMCISION


                  NUTRITION COUNSELING                                            TRAVEL

                                                                                  LIFESTYLE, TOBACCO,
                  BREAST OR BOTTLE FEEDING
                                                                                  ALCOHOL
  RESULTS                                                                                                            TUBAL STERILIZATION
                                                                                                              DATE CONSENT SIGNED        INITIALS


  COMMENTS/COUNSELING




                                                                                                        STANDARD FORM 533 (REV. 12-1999) PAGE 6
                                                                                                                                                                               NSN 7540-00-634-4276

                                                                                              SUPPLEMENTAL VISITS
                                                                           PRETERM LABOR

               WEEKS GEST.




                                                                                              CERVIX EXAM
                                           PRESENTATION
                             HEIGHT (CM)




                                                                                                                                                    MENT (Date)
               (BEST EST.)




                                                                MOVEMENT
                                                                           SIGNS/SYMPTOMS                   BLOOD                         URINE




                                                                                                                                                                  PROVIDER
                                                                                              (DIL./EFF./




                                                                                                                                                    APPOINT-
    DATE                                                                                                    PRES-                       (GLUCOSE/                                  COMMENTS

                             FUNDAL




                                                                                                                            WEIGHT
                                                                                                                    EDEMA




                                                                                                                                                                  (Initials)
                                                                FETAL
                                                                                                             SURE                        ALBUMIN)




                                                                                                                                                    NEXT
                                                                           PRESENT   ABSENT




                                                                                              STA.)
                                                          FHR




PROGRESS NOTES




PATIENT'S IDENTIFICATION (For typed or written entries, give: Name -- last, first, middle; ID No.                                    REGISTER NO.                              WARD NO.
                         or SSN; Sex; Rank/Grade)




                                                                                                                                               STANDARD FORM 533 (REV. 12-1999) PAGE 7
                                                         NSN 7540-00-634-4276
LAST NAME        FIRST NAME   MIDDLE INITIAL ID NUMBER
Stacey           Hockett
PROGRESS NOTES




                                   STANDARD FORM 533 (REV. 12-1999) PAGE 8
                                                                                                                                                NSN 7540-00-634-4276

                                                                       DISCHARGE/POSTPARTUM

                                                                         DELIVERY INFORMATION
DELIVERY DATE                                                                          TYPE OF DELIVERY
                                                        VAGINAL                                                            CESAREAN
DELIVERY AT (Weeks)                         SVD                      EPISIOTOMY                             FOR                             REPEAT-FAILED VBAC
                                                                                             PRIMARY
                                            VACUUM                   LACERATIONS                                                            LOW TRANSVERSE
                                            FORCEPS                  VBAC                    CLASSICAL            REPEAT - ELECTIVE         LOW VERTICAL
                                       LABOR                                                                               ANESTHESIA
     SPONTANEOUS                            AUGMENTED                                        NONE                    EPIDURAL               GENERAL
     INDUCED                                NO LABOR                                         LOCAL/PUDENDAL          SPINAL                 OTHER
                                                                    POSTPARTUM COMPLICATIONS
     NONE                        HEMORRHAGE                 INFECTION                   HYPERTENSION              OTHER:
                                                                                                                                                 DISCHARGE DATE
                                                           DISCHARGE INFORMATION
                                                                                   NEONATAL
                               SEX                                                       DISPOSITION                                  COMPLICATIONS/ANOMALIES
     FEMALE                            CIRCUMCISION                       HOME WITH MOTHER               NEONATAL DEATH
     MALE                        YES                  NO                  TRANSFER                       OTHER
BIRTH WEIGHT               NAME OF BABY                                   STILLBIRTH
                                                                          IN HOSPITAL
                                                                                   MATERNAL
HB/HCT LEVEL                             CONTRACEPTIVE METHOD (If applicable)                             MEDICATIONS


          FEEDING METHOD                 DIAGNOSTIC STUDIES PENDING
     BREAST                BOTTLE
                SECONDARY DIAGNOSIS/PREEXISTING CONDITIONS                                                           FOLLOW-UP APPOINTMENT
     ASTHMA                              OTHER                                            DATE                      LOCATION
     DIABETES
     HYPERTENSION
                                IMMUNIZATIONS GIVEN                                       REMARKS
     D (Rho)(D)) IMMUNE GLOBULIN
     DIABETES
     OTHER:
                                                                            INTERIM CONTACTS
       DATE                                                                            COMMENT




SIGNATURE OF PROVIDER (AS REQUIRED)


PATIENT'S IDENTIFICATION (For typed or written entries, give: Name -- last, first, middle; ID No.         REGISTER NO.                           WARD NO.
                         or SSN; Sex; Rank/Grade)




                                                                                                                      STANDARD FORM 533 (REV. 12-1999) PAGE 9
                                                                                                                 NSN 7540-00-634-4276
LAST NAME                                  FIRST NAME                                 MIDDLE INITIAL ID NUMBER
Stacey                                     Hockett
                                                            POSTPARTUM VISITS
DATE                  ALLERGIES


LAB STUDIES REQUESTED                                               MEDICATIONS/CONTRACEPTION




HGB/HCT                             LAST PAP SMEAR (Date)           MEDICATIONS/CONTRACEPTION DISPENSED
                                                                           YES               NO
INTERIM HISTORY                                                     FEEDING METHOD


                                                                    CONTRACEPTIVE METHOD


                                                  INTERVAL CARE RECOMMENDATIONS
FOR GENERAL HEALTH PROMOTION




FOR REPRODUCTIVE HEALTH PROMOTION




REFERRALS




RETURN VISIT (Date)                 EXAMINED BY


                                                             PHYSICAL EXAM
BP                                           WEIGHT                                        PAP SMEAR
                                                                                                  YES            NO
                        ITEM                  NORMAL        ABNORMAL                               COMMENTS
BREASTS

ABDOMEN

EXTERNAL GENITALS

VAGINA

CERVIX

UTERUS

ADNEXA

RECTAL-VAGINAL
COMMENTS




                                                                                           STANDARD FORM 533 (REV. 12-1999) PAGE 10
                                                                                                                                  NSN 7540-00-634-4276
COMMENTS (Continue on back if needed)




PATIENT'S IDENTIFICATION (For typed or written entries, give: Name -- last, first, middle; ID No. (SSN or   REGISTER NO.            WARD NO.
                         other); hospital or medical facility)




                                                                                                            STANDARD FORM 533 (REV. 12-1999) PAGE 11

				
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