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Link to Word Document with Pediatric Note Templates: Peds_Clinic_Templates.docx
Prenatal Note HPI
Ms. _ is a _ yo G_ P_ at _ with an EDD of _ by _ who presents for prenatal care.
Interim history:
Contractions:
Leaking of fluid:
Vaginal bleeding:
Fetal movement:
Dysuria/abnormal discharge:
Problems this Pregnancy:
1._
PrenatalCare:
The patient is seen at the Southeast Heights Clinic by _.
Initiated prenatal care at _ weeks.
Number of visits: _
Pre-pregnancy weight: _, Recommended weight gain in pregnancy: _
First trimester BP: _.
Tdap vaccination (week 27-36): _
Influenza vaccination: _
TOLAC: _ Op Note Reviewed: _
Plans for Current Pregnancy:
Genetic screen desired?:_
FOB/support person: _
Preferred provider for delivery: _
Labor preferences/Pain control in labor: _
Infant feeding preference: _
Custody issues: _
Circumcision preference: _
Infant medical care plans: _
Postpartum contraception: _
Would accept blood transfusion in emergency?: _
OB History:
G1 _
Gynecological History:
LMP: _ Certain?: _
Abnormal paps?: _
Last pap?: _
STIs?: _
PMHx:
_
PSHx:
_
Social History:
Desired pregnancy?: _
Partner: _
Living situation: _
Employment: _
Education: _
IPV or other abuse/neglect/assault? _
Eating disorder?: _
Tobacco use disorder?: _
Alcohol/other substances?: 4 P's:
Have you used alcohol or substances in the current Pregnancy?: _
Have you had a problem with drugs or alcohol in the Past?: _
Does your Partner have a problem with drugs or alcohol?: _
Do you consider one of your Parents to be an addict or alcoholic?: _
Family History:
Family members with congenital anomalies, deafness, cognitive disability?: _
Family members with hypercoagulable disorders or thromboembolic events? _
Mother: _
Father: _
Siblings: _
Children: _
Others: _
Partner’s pertinent medical history: _
Prenatal Labs:
Blood type: _
AST: _
Hct: _
GC/CT: _
Urine culture: _
Tpab: _
HepB SAg: _
HIV: _
Rub: _
Varicella: _
Genetic screening: _
HgbA1c: _
Pap: _
24-28 week labs:
Repeat Hct: _
1 hour GTT: _
35-37 week labs:
GBS: _
Ultrasounds:
1. _
Controlled Substances
UDM: Has been done within last 6 months. Last done _; Significant results: _
NM PMP: Reviewed _. Appropriate
Last time medication was taken by patient: _
Prescription: _
Frequency of prescription: _
Initial date of current prescription: _
Date opioid first prescribed: _
MME: _ (For MME/day >90, justification for ongoing use: _).
Condition requiring chronic opioid: _
Previous work-up of this condition: _
Other modalities used to treat this condition: _
There has been clinically meaningful improvement in pain and/or function with this use of this chronic opioid: _
Side effects/complications reviewed/discussed with patient.
High Risk Conditions:
_ None
_ Previous substance use disorder
_ Previous overdose on opiates
_ Aberrant behavior
_ Concurrent benzodiazepine use
_ Concurrent pulmonary disease, sleep-disordered breathing, renal impairment or hepatic impairment
_ Naloxone discussed _ prescribed.
Date last contract signed: _
Recommendations for lost Rx, missed appointment, etc.: _
Buprenorphine
Buprenorphine dose: _
Frequency of prescription: _
Initial date of current prescription: _
Recommendations for lost Rx, missed appointment, etc.: _
Buprenorphine Start date: _
UDM: Has been done within last 6 months. Last done _; Significant results: _
Urine buprenorphine metabolites: _
NM PMP: Reviewed _. Appropriate (Checked at minimum Q 3 months)
Last relapse: _
Naloxone Rx and/or education: _
Counseling: _
Date last contract signed: _
FOCUS adult HPI
This is a __ yo patient with history of (hepatitis C, opiate use disorder, etc) who presents for follow up with the FOCUS clinic.
1. Opiate use disorder, in remission, on MAT with Suboxone.
- Current dose (desire to go up or down)
- Symptoms (note patient’s rating for each: craving, withdrawal, anxiety, depression, difficulty
sleeping)
- Recent relapses reported
- Last UDM and today’s POC UDM
- Review of PMP (when last Rx was filled and any other controlled substances filled)
- Engagement with counseling
2. Psychiatric diagnoses (if relevant).
- Current medications and symptoms.
3. Hepatitis C status.
- Hep C antibody: (reactive or nonreactive and date)
- If reactive antibody, do Hep C PCR:
- If PCR +, needs CBC/LFTs and abdominal US:
- If evidence of cirrhosis on US, needs US every 6 months, MELD score (Chem7/LFTs/INR), EGD to screen for varices
- Assess interest in Hep C treatment:
4. Other health conditions (hypertension, hypothyroidism, musculoskeletal concerns, etc)
5. Contraception.
6. HCM:
- Last pap: (and when next is due)
- Immunizations:
- Lipid panel (if > 35), mammogram/colon cancer screening (if > 50)
Referral to Dr. Caro
PCP: _
Reason for Behavioral Health Referral: _Individual/Couples counseling _ Stress management _ Pain Management _ Diagnostic evaluation _ Behavioral change
_ Insomnia _ Other:
Clinical question to be addressed/answered: _
What does the client hope to achieve through counseling?: _
Does the patient understand why they are being referred? _
Level of motivation for change/therapy: _
Urgency: _ Urgent (discuss directly with Dr Caro) _ Routine
Patient's preferred language: _ English, _ Spanish, _ Other: _
Reminders:
- Dr Caro is available for warm hand-offs, will pause current session to meet with new patients
- Send above referral in PCO message to Betty A Vigil and Blanca Caro for scheduling
- Be sure that patient is wanting to have referral to Dr Caro (if not, this should be specified on referral)
- Dr. Caro works with clients presenting with a broad range of problems including sexual and gender identity, diabetes management, and sexual dysfunction (among others)
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