Antepartum Problem Visit Note (Pregnancy Complication)

Visit Header

• Date & time of service: [Date and time]
• Location/setting: [clinic / L&D triage / ED / inpatient / other]
• Gestational age today: [Weeks+days] EDD: [EDD (dating method)] (If gestational age is unknown, document "Dating unknown" and plan to reconcile.)
• Gravida/Para: [G_P_ (standard obstetric notation)]
• Fetal number: [singleton / multiple] (If multiple, include chorionicity/amnionicity if known.)
• Reason for visit: [Concise problem statement]
• Interpreter: [used / not used]; [language]; [ID or modality] (Only if applicable.)

Subjective

Chief concern: [Primary concern, optionally in patient's own words]

HPI: [Focused narrative covering onset, duration, trajectory, severity, context, modifying factors, and impact on activities] (When relevant: address fetal movement compared to baseline; vaginal bleeding amount/color/clots; leakage of fluid character and quantity; contractions pattern/frequency/pain.)

Home monitoring data: [Home BP readings, kick counts, glucose, or other relevant data] (Only if applicable.)

Pertinent history influencing today's decisions: [Key obstetric/medical issues, medications, allergies, prior complications, or recent events directly affecting today's management] (Do not re-document comprehensive histories maintained elsewhere.)

Objective

Vitals: [BP (include repeat if abnormal), HR, Temp, RR, SpO2 as relevant]

Exam:

• Abdomen/uterus: [Tenderness, fundal height, uterine tone, other pertinent findings]
• Other systems: [Cardiopulmonary, extremities, neurologic—pertinent positives/negatives only as indicated by complaint]
• Pelvic/speculum exam: [Indication and key findings] (Only if performed.)

Fetal status: [FHR by Doppler / NST / continuous monitoring]; [Baseline bpm, variability, accelerations/decelerations as applicable]; [Interpretation: reassuring / nonreassuring / indeterminate]; [Uterine activity if assessed]; [Bedside ultrasound findings if performed: viability, presentation, fluid, movement] (Required for viable gestations. If not performed, document reason and plan to obtain.)

Diagnostics: [Pertinent labs/imaging with results; tests ordered and pending; tests considered but not obtained with brief rationale]

Assessment

(List problems in order of severity/urgency.)

[Problem 1]: [Working diagnosis or "concern for..."] — [Brief supporting rationale from today's findings]; Fetal status: [reassuring / nonreassuring / not yet assessed] (Include differential diagnosis when uncertainty is clinically important.)

[Problem 2]: [Working diagnosis or concern] — [Rationale]; Fetal status: [reassuring / nonreassuring / not yet assessed] (Additional problems only if applicable.)

Plan

[Problem 1]: [Interventions (medications, procedures)]; [Diagnostic plan (pending tests, thresholds that would change management)]; [Monitoring (maternal and fetal surveillance type/frequency)]

[Problem 2]: [Repeat structure as applicable]

Return precautions (reviewed with patient): [Worsening bleeding or clots; absent or markedly decreased fetal movement; severe headache or vision changes; chest pain or shortness of breath; severe abdominal pain; leakage of fluid; regular painful contractions; severe-range blood pressure]. Where to seek care: [L&D triage / ED / call on-call clinician] [immediately / within X hours]. Patient verbalized understanding: [Yes / No]

Disposition: [home / direct to L&D / admission / transfer]

Follow-up: [Timeframe and provider/team]; [How pending results will be communicated]

Care coordination: [Consultant contacted, recommendations, and agreed plan; for transfers: maternal and fetal status at decision point, receiving facility, key information communicated] (Only if applicable.)

Signature

[Clinician name, credentials] — [Date/time signed]