MCH Documentation & Templates

Please remember, not every section of these templates is relevant to every patient. For example, if a patient is < 24 weeks and did not have an NST or did not have an ultrasound, please delete that portion of the note.  Do not delete sections (social hx, ROS, etc) or information contained in H&P or other sections. If you do not know just say so, but these are important for clinical and billing reasons. 

• Subutex Start H&P 

• Initial Prenatal Intake Visit

• MCH Cache Format Guide 

• MCH Inpatient Templates  
• L&D Labor Admission H&P
• Postpartum Discharge Summary
• Labor Progress Note
• Maternal Postpartum Progress Note 
• Newborn H&P
• Newborn Progress Note
• Newborn Discharge Summary 

Documentation for Observations

 

Previously we were able to addend an H&P for a discharge summary for short stays.  

3) Do med rec 

4) On the day of discharge: 

 

     1) Write a brief summary of the hospital stay- a few sentences- under the H&P. Title this “Discharge Addendum”

     2) Create a DC Summary note dated on the day of discharge,  and in that note write “please refer to the addendum on the H&P”

Medical Student Documentation

• Medical students may write notes for NON HIGH RISK PATIENTS in lieu of a resident note using one of the medical student attestations below.  This includes H&Ps, triage visits, discharge summaries, daily newborn and postpartum progress notes.  Attendings need to see the patient with the medical student and repeat all elements of exam and history if not present when the student performed them.  Med students should not document on high risk patients, i.e. patients staffed by fellow/back-up. This documentation should still be done by the resident and fellow. 

Medical Student Attestations

   =attending_MSonly

   =attending_MSandResident

   =resident_MS 

Accurately Documenting Complexity of Obstetric Care

 Please put “pregnancy complicated by: XXX” wording in the ASSESSMENT AND PLAN.   Avoid writing “history of” 

                History of is nonspecific and it’s unclear if it’s this pregnancy, has resolved, or a prior pregnancy

                This also needs to be in the Assessment and Plan where we put or medical decision making. Putting this in the HPI is not                  sufficient. 

Right now the coders can’t tell when our management (e.g. for labor in a TOLAC, prior PPH, etc) is driven by these complicating conditions.

 All abbreviations and shorthand must be spelled out at least once in the chart.  “Chorio,” “oligo,” “poly,” “III” etc are not allowed because it could also mean polyuria, polyneuropathy, polycythemia, etc etc – it must say “chorioamnionitis,” “oligohydramnios,” “polyhydramnios” “Triple I” etc.