Proper Documentation of Obstetrical Care

October 19, 2018

Communication between health care professionals during the patient’s pre-pregnancy, pregnancy, and postpartum medical journey is important. It is recommended that when caring for the patient, the following be documented in the patient’s chart to ensure effective coordination and continuity of care:

  • Prenatal Visit in First Trimester:
    • Prenatal risk assessment with counseling to include education, complete medical and obstetrical history, physical exam (e.g., American College of Obstetricians and Gynecologists (ACOG) Form)
    • Prenatal lab reports (OB panel/TORCH antibody panel/Rubella antibody test/ABO/ Rh)
    • Ultrasound, Estimated Date of Delivery (EDD)
  • Duration of Prenatal Visits:
    • Prenatal flow sheet (ACOG, electronic medical record (EMR), or other)
    • All progress/visit notes for duration of pregnancy
    • Ultrasound reports and all consult reports
  • Delivery:
    • Documents, such as hospital delivery records, verifying member had a live birth
    • If the patient had a non-live birth, records that document the non-live birth
  • Postpartum:
    • Documentation of a postpartum visit on or between 21-56 days after delivery
    • Postpartum office visit progress notation that documents an evaluation of weight, blood pressure, breast exam, abdominal exam, and pelvic exam

Thank you for your partnership with us in the care of Blue Cross and Blue Shield of Texas Federal Employee Plan (FEP) members.