Nov. 8, 2019
To help you provide effective coordination and continuity of care for pre and post-natal care and services for our Federal Employee Program® (FEP) members we are providing the following important information.
Documentation to Include in Patient's Chart
When you are providing care, please document the following information in the patient's chart:
Prenatal Visit in First Trimester
- Prenatal risk assessment should include complete medical and obstetrical history, physical exam (e.g., American College of Obstetrics and Gynecology (ACOG) Form) and patient education/counseling
- Prenatal lab reports (e.g., obstetric (OB) panel/toxoplasmosis, rubella, cytomegalovirus, herpes simplex and HIV antibody (TORCH) panel/rubella antibody test/ABO (O, A, B or AB blood group testing)/Rh factor testing)
- Ultrasound, estimated due date (EDD)
Duration of Prenatal Visits
- Prenatal flow sheet (e.g., ACOG, Electronic Health Record (EHR)) All Progress/visit notes for duration of pregnancy
- Ultrasound reports and all consult reports
- Documents, such as hospital delivery records, verifying the member had a live birth
- If the member had a non-live birth, records that document the non-live birth
- Documentation of a postpartum visit on or between 7 to 84 days after delivery
- Postpartum office visit progress notation that documents an evaluation of weight, blood pressure, breast exam, abdominal exam and pelvic exam
Communication between health care professionals during a patient's pre-pregnancy, pregnancy and postpartum medical journey is important. Thank you for your help supporting positive outcomes for our FEP members.
The information mentioned here is for informational purposes only and is not a substitute for the independent medical judgment of a physician. Physicians are instructed to exercise their own medical judgment.