Routine Prenatal Follow-Up Visit Note

Encounter Date: [Encounter date]

Patient: [Patient full name]

Provider: [Provider name, credentials]

Gestational Age: [Weeks+Days]

Estimated Due Date (EDD): [EDD] by [dating basis and source] (If no ultrasound confirmation before 22 weeks: [Dating suboptimal—note reason])

Gravida/Para: [GxPy, include TPAL as applicable] Plurality: [Singleton / Twins / Higher-order multiples]

Pregnancy Snapshot

(Carry-forward section; review and update each visit. If unchanged, document "reviewed, no interval changes.")

• Blood type / Rh: [ABO type]; [Rh status] (If Rh-negative: [RhIG plan and timing])
• Key conditions and risk factors: [Concise problem/risk list]
• Current pregnancy medications: [Medication list]
• Allergies: [Allergen and reaction type]
• Screenings and immunizations: [Test/vaccine: status and date] (Status terms: Due / Completed / Ordered / Pending / Declined)

Subjective

[Interval history since last prenatal contact including new symptoms, ED/L&D visits, hospitalizations, medication adherence, new exposures, and patient questions for today]

OB Symptom Screen: (For any positive, characterize onset/severity/pattern and ensure action in Plan)

• Vaginal bleeding: [present / absent] [If present: characterization]
• Leakage of fluid: [present / absent] [If present: characterization]
• Contractions or regular tightening: [present / absent] [If present: frequency, duration, intensity]
• Fetal movement change: [present / absent] [If present: description]
• Preeclampsia warning symptoms: [present / absent] [If present: which symptoms and severity]

Objective

Vitals: (BP required each visit. If abnormal, document cuff size, position, repeat. For telehealth, label patient-reported with source.)

• Blood pressure: [Value] [If not obtained: reason]
• Weight: [Value]

OB Measurements:

• Fundal height: [cm] [If not obtained: reason]
• Fetal heart rate: [bpm] by [doppler / NST / ultrasound] [If not obtained: reason]
• Presentation (if assessed): [cephalic / breech / transverse / unknown]

Exam: (Pertinent findings only; pelvic/cervical exam only when clinically indicated with documented indication)

[Pertinent findings by system as relevant; pelvic/cervical findings if performed with indication]

Data Reviewed: (Omit if no results since last visit)

• [Test name] — [Date]: [Key result]; [Interpretation/action]

Assessment

[Pregnancy summary: gestational age, dating basis, maternal-fetal status]

• [Active problem] — [One-line current status]
• [Additional problems as applicable] — [One-line current status]

Plan

(Organize by problem. For each: status with data, medication changes with rationale, monitoring, orders, referrals, counseling.)

[Problem 1]

[Current status with supporting data; medications; monitoring plan; orders; referrals; counseling provided]

[Additional Problems]

(Repeat structure for each active problem)

Routine Prenatal Care

• Milestone actions today: [Completed / Ordered / Counseled items]
• Screening/immunization status: [Items with Due / Completed / Ordered / Pending / Declined and dates]
• Anticipatory guidance: [Topics appropriate to gestational age]

Follow-Up

• Next visit: [Interval or GA target] [in-person / telehealth]
• Planned: [Assessments/tests expected at next visit]
• Return precautions: [When to call clinic or present to L&D]