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Discipline

: Obstetrics & Gynaecology

Sub Discipline

: Obstetrics And Gynaecology

Document Title

: Obstetrics Clerking Note

PRESENT PREGNANCY

Referral From

Risk Level Booking

Present Pregnancy

Period Cycle

Gestation Noted By 1st USG

Week(s)

First Trimester Dating Scan

Date Of 1st Trimester Usg

Date of Last Contraception

Contraception Usage

Pills

POP

Intrauterine device

Implant

Injections

Barrier

Traditional

Natural

Others, specify

Unknown

Date of 1st Booking

Place Of Antenatal Care Received

Health Clinic

Government Hospital with specialist

Government Hospital without specialist

Private Hospital / Clinic

Mobile Clinics

No antenatal care

Unknown

Others, specify

State

District

If Foreign, Specify

Early Pregnancy Problems

Bleeding

Hyperemesis

Urinary tract infection

DVT

Epileptic fits

Lethargy

Backache

Mood Changes

Gastritis

Pelvic Pain

None

Others, specify

Presenting Complaints

None

Abdominal Pain

Contractions

Premature contraction

Regular contraction

Nausea and vomiting

P/V bleeding

P/V staining

P/V discharge

Show

No fetal movement

Reduce Fetal Movement

Leaking Liquor

Giddiness

Headache

Heart Burn

Gastritis

Fainting attack

Blurring of visions

Epigastric pain

Lethargy

Frequency of micturation

Liver Impairment

Difficulty in Breathing

Dysuria

Breathlessness

Backache

Leg pain

Calf pain

Anaemia

IUGR

Postdate

Uncontrolled BP

Uncontrolled blood sugar

Others, specify

Present Obstetrics History

Type Of Conception

SpontaneousAssisted

Drug Used

Clomid

Procedures

ICSI

ANTENATAL SCREENING

MOGTT

YesNo

ABO

RH

Rhogam Given

YesNo

Syphilis

YesNoUnknown

TPHA

No

HIV

On Treatment

YesNo

Other Infective Screen, specify

Please Update Method

Current Medication

None

Antibiotics

Ampicillin

Unasyn

Augmentin

Cephalosporins

Others, specify

Anticoagulants

Heparin

Clexane

Tinzaparin

Warfarin

Others, specify

Antiepileptics

Carbamazepine

Sodium Valproate

Others, specify

Antihypertensive

Methyldopa

Labetalol

Nifedipine

Others, specify

Antipsychotic Drugs

Risperidone

Others, specify

Asthma

Salbutamol

Singular

Neulin

Others, specify

Haematinics

Obimin

Ferrous Sulphate

Iberet Folate

Zincofer

Venofer

Imferon

Others, specify

Hypoglycaemic Agents

Insulin

Metformin

Others, specify

Mg So4

Prematurity

Severe Preeclampsia

Eclampsia

Others, specify

Thyroid Medication

Propylthiouracil

Carbimazole

L-Thyroxine

Others, specify

Others, specify

HISTORY PAST OBSTETRICS / GYNAE

Past Obstetrics History

Past Obstetrics History

Please Update Method

Gynae Operation / Problems

Gynae Operation / Problems

None

Subfertility

Myomectomy

ERPOC

Molar Pregnancy

Laparoscopy

Ovarian Cystectomy

Endometriosis

STD

Ovulation induction

Others, specify

Date Of Last Pap Smear

Comments

Result Of Pap Smear

NormalAbnormal

Comments

Medical History

Medical History

None

Diabetes

Hypertension

Heart Disease

Classification

Bronchial Asthma

Renal disease

Thyroid disease

Connective tissue

Epilepsy

Others, specify

Past Surgical History

Allergies And Alert

Allergies

Vaccination / Immunisation

Tetanus Toxoid First Dose

Tetanus Toxoid Additional Dose

Family History

Allergies

Diabetes

Hypertension

Multiple Pregnancy

Tuberculosis

Congenital anomaly

Others, specify

Social History

Occupation

Level Of Education

Husbands Occupation

Household Income Per Month

Social Welfare

Smoking

Substance Abuse

Alcohol

Drugs

Others, specify

GENERAL EXAMINATION

Vital Signs & Other Observations

Pallor

Comments

Oedema

Nil

General

Pedal

Sacral

Others, specify

Comments

Jaundice

Comments

Hydration

Comments

Varicose Veins

Nil

Lower Limb

Vulval

Others, specify

Comments

Thyroid

Normal

Enlarged

Others, specify

Comments

Oral Cavity

Healthy

Unhealthy

Few dental caries

Others, specify

Comments

Cardiovascular

NormalAbnormal

Respiratory

NormalAbnormal

Neurological

NormalAbnormal

Breast

Please Update Method

Lymph Nodes

NormalAbnormal

Peripheral Pulses

NormalAbnormal

Gastro - Intestinal

NormalAbnormal

General Examination Comments

Abdominal Examination

Abdomen

Comments

Contraction

PresentAbsent

Fundal Height (Weeks)

Symphysis Fundal Height (cm)

No Of Fetuses

Liquor Volume Estimation

Comments

Fetal Lie

Comments

Presenting Part

Comments

Engagement

Comments

Fetal Heart

Comments

Fetal Movement

Comments

Estimated Birth Weight

Comments

Vaginal Examination

Vulva

Normal

Varicose veins

Warts

Ulceration

Warts with ulcer

Varicose veins with warts

Herpetic lesions

Mutilated

Others, specify

Comments

Vagina

Normal

Septum

Stenosis

Discharge present

Inflamed

Cystocoele

Rectocele

Enterocoele

Vaginal cyst

Others, specify

Comments

Discharges

Nil

Leaking Liquor

Show mucus with blood

Fresh blood

Yellowish discharge

Greenish discharge

Curd-like discharge

Bacterial vaginosis

Urine

Others, specify

Comments

Bishop Score

Dilatation (Cm)

Length Of Cervix (Cm)

Consistency Of Cervix

Position

Bishop Score

Dilatation (cm) Length of cervix (cm) Consistency of Cervix Position Bishop Score

Presenting Part

Position Of Vertex

Membrane

Comments

Arm

Comments

Liquor

Normal

None

Minimal

Excessive

Clear

LMSL

MMSL

TMSL

Foul smelling

Blood stained

Others, specify

Comments

Caput

Comments

Moulding

Pelvic Assessment

Adequate

Not Adequate

Borderline

Others, specify

Comments

Other 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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