Date: [DATE]
Patient: [Patient Name]
MRN: [Medical Record Number]
LMP (Last Menstrual Period): [Date]
Estimated Gestational Age (EGA): [Weeks] Calculated by healthcare provider based on LMP or ultrasound
Reason for Visit:
Document the reason for this visit. Is this the initial prenatal visit, a follow-up for confirmation of pregnancy, or a visit to address specific concerns?
Subjective:
Pregnancy confirmation: Document how pregnancy was confirmed (positive home pregnancy test, blood test).
Prenatal vitamins: Inquire about prenatal vitamin use and any difficulties with adherence.
Symptoms:
Nausea and vomiting (frequency and severity)
Breast tenderness
Fatigue
Frequent urination
Food cravings or aversions
Bleeding or spotting (amount, color, timing)
Pelvic pain or cramping
Past medical history: Briefly document any relevant past medical conditions, surgeries, or allergies.
Social history:
Smoking, alcohol, and illicit drug use (past and present)
Caffeine intake
Occupational exposures
Objective:
Vital Signs: Include blood pressure, weight (if appropriate).
Physical Exam:
General: Assess overall health and appearance.
Abdominal: Palpate for uterine enlargement (if appropriate for gestational age).
Pelvic: May be performed to confirm pregnancy and assess for any abnormalities (consider cervical motion tenderness if indicated).
Breast exam: Assess for lumps or tenderness.
Laboratory:
Document any laboratory tests performed, such as:
Urine pregnancy test (if not already positive)
Complete blood count (CBC)
Blood type and Rh factor
Rubella, varicella-zoster virus (VZV), hepatitis B, and other immunities (if not previously documented)
Thyroid stimulating hormone (TSH)
Imaging:
Document any imaging studies performed, such as:
Early pregnancy ultrasound (transvaginal or abdominal) to confirm fetal viability, assess gestational age, and rule out ectopic pregnancy (if indicated)
Assessment:
Intrauterine pregnancy confirmed at [EGA] weeks by [method of confirmation, e.g., ultrasound, positive pregnancy test].
Consider dating discrepancy if LMP and ultrasound findings differ.
Document any pregnancy-related symptoms and address concerns.
Plan:
Prenatal Care:
Schedule follow-up prenatal visits based on gestational age and individual risk factors.
Discuss the importance of a healthy diet and regular exercise.
Recommend educational resources on pregnancy and childbirth.
Prenatal Testing:
Discuss options for prenatal testing, such as:
First-trimester combined screening (blood test and nuchal translucency scan) for Down syndrome and other chromosomal abnormalities.
Cell-free fetal DNA testing (non-invasive prenatal testing) for chromosomal abnormalities.
Amniocentesis or chorionic villus sampling (invasive prenatal testing) for definitive diagnosis of chromosomal abnormalities (if indicated).
Consider the patient’s wishes and risk factors when discussing testing options.
Medications:
Review current medications and advise on pregnancy safety.
Prescribe prenatal vitamins with folic acid.
Follow-up:
Schedule the next prenatal visit.
Address any patient concerns or questions.
Provide resources for educational materials and support groups.
Note: This is a template and should be adapted to the specific patient encounter. Document all relevant details regarding pregnancy confirmation, symptoms, risk factors, physical exam findings, laboratory and imaging results, and individualized plan for prenatal care, testing, and management.