Documentation During Pregnancy – Federal Employee Program

November 28, 2018

Communication between health care professionals during the course of a patient’s pre-pregnancy, pregnancy, and postpartum medical journey is important. It is recommended that when furnishing obstetrical care to your patient, at least the following be documented in the patient’s chart to facilitate more effective coordination and continuity of care via records shared with other providers:

  • Prenatal Visit in First Trimester:
    • Prenatal risk assessment with counseling to include education, complete medical and obstetrical history, physical exam (e.g. ACOG Form)
    • Prenatal lab reports (OB panel/TORCH antibody panel/Rubella antibody test/ABO/ Rh)
    • Ultrasound, EDD
  • Duration of Prenatal Visits:
    • Prenatal flow sheet (ACOG, 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 caring for our Blue Cross and Blue Shield Service Benefit Plan members.