High-Risk Prenatal Visit Note

Date: [date of visit]

Provider: [clinician name and credentials]

GA: [weeks+days] (EDD [date] by [LMP / early ultrasound with date and GA / IVF transfer date]) (If dating basis unclear, document best estimate used and note records requested.)

Pregnancy: [singleton / multiple with chorionicity/amnionicity if applicable]

High-Risk Conditions: [brief list of active conditions making this pregnancy high-risk]

Interval History

[Interval events since last visit] (Summarize hospitalizations, triage visits, medication changes, new diagnoses, adherence concerns. If none, state "No interval events.")

Obstetric Symptom Screen (Do not infer responses. Document exactly what was asked and answered. If not assessed, state "not assessed" with reason.):

• Fetal movement: [normal / decreased / absent / not assessed]
• Vaginal bleeding: [present / absent / not assessed]
• Leakage of fluid: [present / absent / not assessed]
• Contractions/uterine activity: [regular / irregular / cramping / absent / not assessed]
• Preeclampsia warning symptoms:
  • Headache: [present / absent / not assessed]
  • Visual changes: [present / absent / not assessed]
  • RUQ/epigastric pain: [present / absent / not assessed]
  • Sudden swelling: [present / absent / not assessed]
  • Dyspnea: [present / absent / not assessed]

Home BP Monitoring (if applicable): [range/average, frequency, technique concerns] (If logs unavailable, state explicitly and include any verbal report.)

Glucose Log Review (if applicable): [% in target, hyper/hypoglycemia patterns, episodes] (If logs unavailable, state explicitly and include any verbal report.)

Objective

• Vitals: [BP (repeat if elevated), HR, weight, urine dip if performed]
• Exam: [pertinent maternal findings—general appearance, fundal assessment, edema, reflexes if hypertensive symptoms] (Cervical exam only if clinically indicated; document chaperone if performed.)
• Fetal Status: [FHR by Doppler, fundal height, presentation if assessed] (If NST/BPP performed: baseline, variability, accelerations, decelerations, interpretation.)
• Data Reviewed: [relevant labs, imaging, monitoring logs, external records with dates—include only decision-relevant findings and trends]

Assessment & Plan

(Organize by active high-risk problem in order of severity. For each problem, address: current status with metrics, treatment plan with doses, surveillance plan with timing, and delivery planning considerations. Document shared decision-making and patient preferences. If patient declines recommendation, document: recommendation made, risks of declining, patient's reason, and contingency plan.)

[Problem 1: condition name]

[Current status and control with key metrics. Treatment plan including medication changes with doses. Surveillance plan with specific tests and timing. Delivery planning considerations. Shared decision-making if applicable.]

[Problem 2: condition name]

[Current status and control with key metrics. Treatment plan including medication changes with doses. Surveillance plan with specific tests and timing. Delivery planning considerations. Shared decision-making if applicable.]

[Additional problems as needed]

[Follow same structure for each active high-risk condition.]

Condition-specific guidance:

• Hypertensive disorders: Include BP trends (clinic and home), medication adjustments, aspirin prophylaxis status, preeclampsia workup if indicated, growth/Doppler surveillance schedule, delivery timing thresholds.
• Diabetes: Include glycemic control summary against targets (fasting <95, 1-hr postprandial <140 or 2-hr <120 mg/dL), medication titration, monitoring frequency, growth/AFV surveillance, delivery timing.
• Preterm birth risk: Include cervical length results and trend, current interventions per up-to-date evidence, symptom education provided, delivery considerations.

Pregnancy-Wide Items (if actionable today)

[Immunizations given/declined/scheduled, third-trimester labs, antenatal testing initiation, delivery location/level of care planning, pending consults]

Return Precautions

(Tailor to patient's specific risk profile with explicit actions and destinations.)

• Preterm labor: Regular contractions, pelvic pressure, bleeding, or fluid leakage → [proceed to L&D triage]
• Preeclampsia: Severe headache, visual changes, RUQ pain, dyspnea, or home BP ≥[threshold] → [proceed to L&D triage / call EMS if severe]
• Fetal movement: Decreased or absent movement → [proceed to L&D triage]
• Diabetes (if applicable): Hypoglycemia not responding to treatment or persistent hyperglycemia with vomiting/ketones → [call clinic / proceed to L&D triage]
• Emergency: Severe bleeding, chest pain, or respiratory distress → [call emergency services]

Follow-Up

• Next appointment: [date/time, location, visit type]
• Pending results: [tests pending with expected dates and communication plan]
• Scheduled surveillance: [upcoming NST/BPP, ultrasounds, labs with dates]