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Obstetrics Outpatient Assessment Note

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PREGNANCY

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GENERAL EXAMINATION

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Vital Signs & Other Observations

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Pallor

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Comments

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Oedema

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Comments

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Jaundice

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Comments

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Hydration

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Comments

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Varicose Veins

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Comments

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Thyroid

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Comments

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Oral Cavity

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Comments

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Cardiovascular

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Respiratory

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Neurological

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Breast

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Lymph Nodes

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Peripheral Pulses

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Gastro - Intestinal

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Liver

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Kidney

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Spleen

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Skin

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Eyes

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Ears

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Psychiatric

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General Examination Comments

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Abdominal Examination

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Abdomen

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Comments

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Fundal Height (Weeks)

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Symphysis Fundal Height (cm)

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No Of Fetuses

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Liquor Volume Estimation

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Comments

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Fetal Lie

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Comments

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Presenting Part

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Comments

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Engagement

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Comments

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Fetal Heart Rate

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Comments

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Fetal Movement

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Estimated Birth Weight (kg)

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Abdominal Examination Comments

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Vaginal Examination

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Vulva

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Comments

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Vagina

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Comments

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Discharges

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Comments

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Bishop Score

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Dilatation Of Cervical (Cm)

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Length Of Cervix (Cm)

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Consistency Of Cervix

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Position Of Cervix

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Bishop Score

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Presenting Part

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Membrane

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Comments

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Arm

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Comments

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Liquor

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Comments

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Position Of Vertex

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Comments

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Caput

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Comments

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Moulding

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Pelvic Assessment

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Comments

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Other Findings

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DIAGNOSIS

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Diagnosis

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Concurrent Illnesses

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Co-Morbidities

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Associated Problems

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Risk

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Comments

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ANTENATAL HYPERTENSION

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Type - Antenatal Hypertension

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Symptoms

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Signs

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Functional Changes

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Antenatal Hypertension - Management

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Place Of Management

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Hypertension - Ward Urine Protein

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Comments

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Antenatal Hypertension-Outcome

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Comments

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HEART DISEASES IN PREGNANCY

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OTHER PROBLEM IN OBSTETRICS

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RESULTS REVIEW

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MANAGEMENT

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Plan

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Comments

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Follow Up

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Comments

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Referral

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Outgoing

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Comments

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Orders

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Others, Specify

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DISMISSAL ARRANGEMENT

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SIGNATURES

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