Initial Prenatal Visit Note (OB Intake)

Date/Time: [Encounter date and time]

Patient: [Full name], [DOB], [MRN]

Author: [Clinician name and credentials]

Setting: [clinic / telehealth]; [Location]

Interpreter: [Interpreter language]; [Interpreter ID] (Only include if interpreter used; otherwise omit this line.)

Chaperone: [Chaperone name/ID] (Only include if breast/pelvic/genital exam performed today; otherwise omit this line.)

Chief Complaint

[Chief complaint in one concise line]

Pregnancy Summary

Status line: [G/P status] at [gestational age today] by [dating method]; EDD [assigned EDD]; [visit purpose]. (Construct one sentence summarizing gravida/para, gestational age, dating method, EDD, and visit purpose.)

Dating basis:

• LMP: [Date], [reliability assessment], [cycle regularity], [recent hormonal contraception if relevant]
• Conception date: [Ovulation / IUI / IVF transfer date] (Include only if known.)
• Ultrasound dating: [Date], [modality], [CRL measurement], [GA estimate], [source] (Include only if completed and reviewed.)
• Assigned EDD: [EDD] based on [rationale]
• EDD change: Prior EDD [date] changed to [new date] because [reason]; patient informed [yes / no] (Include only if EDD changed.)

Viability and location status:

• IUP status: [confirmed / not confirmed / uncertain]; basis: [ultrasound findings / outside report / none]
• Viability status: [confirmed / not confirmed / uncertain]; basis: [fetal cardiac activity on US / fetal heart tones by Doppler / outside report / none]
• Risk-relevant symptoms: [Bleeding, pain location/severity/timing, syncope] (Include only if IUP/viability not confirmed and symptoms present.)
• Plan for confirmation: [Return precautions, timing for repeat hCG/US, ED indications] (Include if viability/location not yet confirmed.)

Pregnancy context: [Pregnancy intention, patient goals, partner involvement preferences] (Include only if explicitly discussed.)

History of Present Pregnancy

[Narrative summary of presenting symptoms: onset, duration, frequency, severity of nausea/vomiting, breast tenderness, fatigue; any bleeding, spotting, cramping, unilateral pain with location/severity/timing; syncope or ectopic risk flags; infection symptoms if present]

[Medication and substance exposures since conception: prescription, OTC, herbals; alcohol with timing of last use; tobacco/nicotine/vaping; cannabis; other substances; prenatal vitamin and folic acid use; dietary restrictions; occupational or environmental exposures of concern] (Do not infer negatives unless explicitly asked and answered.)

[Prior pregnancy testing and outside records: home/clinic pregnancy test dates and results; outside ultrasound reports reviewed; ED or urgent care visits related to this pregnancy]

Obstetric History

• [Year]: [GA at outcome], [outcome type: term / preterm / SAB / TAB / ectopic], [delivery mode and indication if cesarean], [maternal complications], [neonatal outcomes] (Repeat for each prior pregnancy.)
• [Cervical procedures or preterm birth prevention history] (Include only if applicable.)

(If no prior pregnancies: G1—current pregnancy; no prior pregnancies.)

Gynecologic History

• Menstrual history: [Menarche age, cycle pattern] (Include if relevant to LMP reliability.)
• Contraception: [Prior methods, recent discontinuation timing]
• Cervical screening: [Last Pap/HPV date and result; history of dysplasia or procedures] (If records not available, state records requested.)
• STI history: [Infections and treatments]
• Gynecologic surgeries: [Procedures, noting uterine cavity entry]
• Infertility: [History and treatments] (Include if applicable.)

Past Medical History

• [Chronic conditions relevant to pregnancy: HTN, diabetes with type and control, kidney disease, autoimmune/thyroid disease, thrombophilia/VTE history, cardiac/pulmonary disease, neurologic conditions, infectious disease history, psychiatric diagnoses with current stability, prior transfusions/alloimmunization]

Past Surgical History

• [Year] — [Procedure] (Include abdominal/uterine surgeries, bariatric surgery, cervical procedures, other surgeries relevant to anesthesia or pregnancy care.)

Medications and Allergies

Medications (reconciled):

• [Medication name] — [Dose] [Route] [Frequency]; [Indication]
• [OTC, supplements, herbals]
• [Prenatal vitamin formulation and folic acid dose]

Allergies:

• [Substance] — [Reaction type and severity]; [IgE-mediated / intolerance]

(If allergy status not reviewed, do not document NKDA; state: Allergies not reviewed—[reason and plan].)

Family and Genetic History

• [First-degree relatives with congenital anomalies, genetic disorders, intellectual disability with syndromic features, early sudden death]
• [Hemoglobinopathy ancestry relevant to screening]
• [Family history of recurrent pregnancy loss, stillbirth, preeclampsia]
• [Consanguinity] (Include if applicable.)
• [Partner genetic history] (Include if available.)

Social History and Screening

Living situation and social needs: [Housing stability, food security, transportation, employment, ability to attend visits, insurance or financial barriers] (Include only items discussed.)

Substance use: [Tobacco/nicotine/vaping status; alcohol; cannabis; other drugs; cessation readiness and resources offered] (Do not infer negatives unless explicitly asked and answered.)

IPV screening: Performed privately: [yes / no]; result: [negative / positive / declined]. (If positive, document only what is necessary for care and safety.)

Mental health screening: [Tool: PHQ-9 / EPDS / GAD-7 / other], score [score], [interpretation], [follow-up plan]. (If positive for suicidality, document safety assessment and plan.)

Other relevant factors: [Exercise, nutrition concerns, occupational exposures, environmental risks, travel] (Include only if discussed.)

Review of Systems

(Document only systems reviewed. Do not auto-populate all systems negative.)

• Constitutional: [Fever, weight change]
• GI: [Nausea/vomiting, abdominal pain]
• GU: [Bleeding, discharge, dysuria]
• Neurologic: [Syncope, severe headache]
• Psychiatric: [Mood, anxiety]
• [Other systems reviewed]

Physical Exam

Vitals: BP [BP], HR [HR], RR [RR], Temp [Temp], SpO2 [SpO2], Height [Height], Weight [Weight], BMI [BMI]

• General: [Appearance and comfort level]
• Thyroid: [Findings]
• Cardiovascular: [Rate, rhythm, murmurs, edema]
• Respiratory: [Effort, breath sounds]
• Abdomen: [Tenderness, masses, uterine size if palpable]
• Extremities: [Edema, tenderness]

Breast and pelvic exam: [Performed / deferred]; indication: [indication]; findings: [findings]; chaperone: [name/ID]. (Include only if performed. If deferred, state reason.)

Fetal heart tones: [Detected at rate / not detected / not assessed]; [plan if not detected]. (Include only if Doppler assessment performed.)

Ultrasound

(Include only if performed today or outside report reviewed.)

• Study: [Date], [modality: transvaginal / transabdominal], [operator]
• Findings: [Gestational sac, yolk sac, fetal pole, CRL, cardiac activity with rate, adnexa]
• Impression: [Dating, viability, location assessment]
• Outside report reviewed: [Facility, date, key findings] (Include only if applicable.)

Assessment

(Problem-oriented list with highest clinical risk first.)

1. [Pregnancy dating: gestational age today and EDD with basis]
2. [Viability and location status as known today]
3. [Maternal medical and psychiatric comorbidities affecting pregnancy]
4. [Obstetric risk factors: prior preeclampsia, prior preterm birth, prior cesarean, etc.]
5. [Social or structural factors impacting care access]

(If symptoms suggest ectopic or early pregnancy loss, explicitly document differential and safety plan. Do not minimize uncertainty.)

Plan

Dating and Viability

• EDD assigned today: [yes / no]; patient informed: [yes / no]
• [Plan for dating ultrasound and interim precautions if dating uncertain]
• [Plan for follow-up imaging and symptom-triggered escalation if viability not confirmed]

Initial Prenatal Labs

• Ordered today: [CBC, blood type and antibody screen, syphilis, HIV, hepatitis B surface antigen, hepatitis C, rubella immunity, urine culture, GC/CT NAAT if indicated, Pap/HPV if due]
• Results reviewed today: [Results with interpretation and action] (Include only if available.)
• Rh status: [Status and plan; Rh immune globulin candidacy if Rh-negative]

Genetic Screening

• Options discussed: [cfDNA, serum screening, carrier screening for CF/SMA/hemoglobinopathies, diagnostic testing]
• Decision: [Accepted specific test(s) / declined / undecided with follow-up plan]
• Genetic counseling referral: [Yes / no / not indicated] (Include if indicated.)

Infectious Disease Screening Plan

• Syphilis: [Rescreening plan: third trimester and/or delivery]
• HIV: [Testing approach and retest plan if high risk]
• Hepatitis B/C: [Screening status and plan]
• STI rescreening: [Plan if risk factors persist]

Immunizations

• Current status: [Influenza, COVID-19, Tdap, RSV]
• Given today: [Vaccines administered]
• Planned: [Tdap 27–36 weeks; RSV 32–36 weeks if in season]
• Declined: [Vaccines declined with counseling documented and plan to revisit]

Risk Reduction

• Preeclampsia: Risk factors: [list]; aspirin prophylaxis: [yes with dose and start timing / no / not indicated]
• Gestational diabetes: [Routine screening at 24–28 weeks / early testing indicated because (indication)]
• Weight gain target: [Target based on BMI category]
• Tobacco/substance cessation: [Resources provided] (Include if applicable.)
• Mental health follow-up: [Plan] (Include if screening positive.)

Counseling Provided

• [Prenatal vitamins and folic acid, nutrition, weight gain expectations, exercise]
• [Substance avoidance, food safety, medication safety in pregnancy]
• [Warning signs and return precautions, how to contact practice and after-hours triage]

Social Needs

• Referrals placed: [Social work, WIC, housing, transportation, behavioral health, community resources]
• Care delivery adjustments: [Visit frequency, telehealth options, transportation assistance] (Include if needed.)

Follow-up

• Next visit: [Timing and purpose]
• Upcoming milestones: [NT window, anatomy US timing, diabetes screening, third trimester labs, GBS]
• [Rationale if schedule deviates from standard]

Orders Summary

• Labs: [Labs ordered today]
• Imaging: [Imaging ordered today]
• Referrals: [Referrals placed today]
• Patient instructions: [Instructions provided]
• Declined services: [Tests/services declined with follow-up plan]

(If a section was not addressed and is not essential for immediate safety, omit it rather than including placeholder text. If essential information is missing, state status as unknown/not yet obtained/deferred with reason and plan. Do not infer that pregnancy was planned, that patient denies substance use, or that there are no allergies unless explicitly stated. Dating and EDD should never be inferred; document uncertainty and plan if unclear.)