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Discipline

: Obstetrics & Gynaecology

Sub Discipline

: Obstetrics And Gynaecology

Document Title

: Obstetrics Clerking Note (New)

PRESENT PREGNANCY

Referral From

Risk Level Booking

Present Pregnancy

Early Pregnancy Problems

Presenting Complaints

Present Obstetrics History

ANTENATAL SCREENING

MOGTT

YesNo

ABO

RH

Rhogam Given

YesNo

Syphilis

YesNoUnknown

TPHA

No

HIV

On Treatment

YesNo

Current Medication

HISTORY PAST OBSTETRICS / GYNAE

Past Obstetrics History

Past Obstetrics History

Past Surgical History

Allergies And Alert

Allergies

Family History

GENERAL EXAMINATION

Vital Signs & Other Observations

Findings

RESULTS REVIEW

Comments On Investigations

Comments On Ultrasound

Comments On Histology

DIAGNOSIS

Diagnosis

Concurrent Illnesses

Co-Morbidities

Associated Problems

Comments

MANAGEMENT

Plan

Follow Up

Comments

Orders

REFERRAL

Referral

Outgoing Referrals

Others, Specify

SIGNATURES

Notes Component

PRESENT PREGNANCY
ANTENATAL SCREENING
HISTORY PAST OBSTETRICS / GYNAE
GENERAL EXAMINATION
RESULTS REVIEW
DIAGNOSIS
MANAGEMENT
REFERRAL
SIGNATURES

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