PRENATAL CARE RECORD

User Guide: Prenatal Care Form

This user guide will help healthcare providers effectively use the prenatal care record form to document patient information throughout pregnancy.

Overview

The Prenatal Care Record is a comprehensive form designed to track all aspects of prenatal care from initial visit through delivery. It includes sections for patient information, medical history, physical exams, laboratory results, and visit tracking.

Form Sections

1. Patient Information

• Full Name: Enter the patient's complete legal name
• Date of Birth: Use the date picker or enter in MM/DD/YYYY format
• Patient ID: Enter the patient's unique identifier from your system
• Address: Include full mailing address
• Phone Number: Primary contact number
• Emergency Contact: Name of person to contact in emergencies
• Emergency Phone: Phone number for emergency contact

2. Obstetrical History

• Gravida: Total number of pregnancies (including current)
• Para: Number of live births
• Abortions: Number of miscarriages or elective terminations
• Living Children: Number of currently living children
• LMP: First day of last menstrual period (critical for dating pregnancy)
• Estimated Delivery: Calculated delivery date (typically 40 weeks from LMP)
• Previous Complications: Document any complications from prior pregnancies

3. Medical History

• Chronic Conditions: Check all that apply; specify "Other" conditions
• Previous Surgeries: List any significant surgical history
• Current Medications: Include prescription, OTC, and supplements
• Allergies: Document medication, food, and environmental allergies

4. Family History

• Genetic Disorders: Any family history of inherited conditions or birth defects
• Chronic Diseases: Family history of diabetes, hypertension, etc.

5. Social History

• Substance Use: Document smoking, alcohol, and drug use patterns
• Occupation: Current employment
• Marital Status: Current relationship status

6. Initial Physical Exam

• Vital Signs: Document baseline measurements
• BMI: Will auto-calculate if height and weight are entered
• System Exams: Document findings for each system

7. Obstetrical Exam

• Fundal Height: Measured in centimeters from pubic symphysis
• Fetal Heart Rate: Measured in beats per minute
• Fetal Position: Presentation of baby
• Ultrasound Findings: Document any ultrasound results

8. Laboratory Results

• Table Format: Record results with dates for all standard prenatal labs
• Normal Ranges: Reference values provided for some tests

9. Prenatal Visit Record

• Tracking Table: Document parameters at each prenatal visit
• Multiple Rows: Use additional rows for subsequent visits
• Gestational Age: Can be recorded in weeks+days (e.g., 28+3)

10. Education and Counseling

• Topics Discussed: Check all topics covered during visit
• Additional Notes: Document any specific patient education provided

11. Provider Notes and Plan

• Assessment and Plan: Document clinical impression and management plan
• Next Appointment: Schedule follow-up visit
• Signature: Provider should sign and date the form

Using the Form

Digital Use

1. Tab between fields or click to select specific fields
2. Use date pickers (calendar icon) for date fields
3. Check appropriate boxes for categorical data
4. Print completed form for physical chart or electronic upload

Printing

• Click the "Print Form" button at top or bottom of the form
• The form is optimized for standard 8.5" × 11" paper
• Print preview to ensure all content fits correctly
• No-print elements (buttons) will not appear on printed version

Best Practices

1. Complete all relevant fields at initial visit
2. Update form at each prenatal visit
3. Document abnormal findings with additional details
4. Review previous entries at each visit for continuity
5. Ensure provider signature and date on final version

Technical Notes

• The form uses standard HTML form elements compatible with most browsers
• No browser-specific features are required
• Form data is not automatically saved - ensure you save or print after completion
• For electronic health record systems, this form can be adapted for digital data entry

Troubleshooting

• If dates aren't displaying correctly, check your browser's date format settings
• If the print layout is incorrect, check your printer's margin settings
• Ensure JavaScript is enabled for optimal functionality

This form provides a structured approach to prenatal care documentation, helping ensure comprehensive care throughout pregnancy while maintaining accurate records.