if you were transcribing this report, how would the appropriate and accurate use of obstetrical terminology support the following in performing their jobs:
ICD-10-CM/PCS coders
Nurses
Physicians Painted Valley, USA
Montero, Elena C Dr. Amber Shephard 126 #706203
PREPARTUM STANDING ORDERS
1.
2.
3.
Check fetal heart tones and vital signs.
Urinalysis
CBC
4
Call physician.
Perineal prep Fleets or soft suds enema as ordered. h.
5.
7.
NPO except for ice chips.
8. 5% D/W in Labor Room. Infuse at 150cc/hour. 9. Notify physician of progress for sedation order.
10. Apply fetal monitor.
11. May be up to shower if not in active labor,
bleeding, or fetal distress.
12. May administer oxygen at 10 liters per mask
for fetal distress then notify physician.
Amber Shephard
Delivery Room
11/14/xx
I 2 Pitucin U10 in IV after delivery of placenta. If no TV, Pitocin U10 IM.
Amber Shephard
11/14/xx S:31pm Adruit and follow routine
orders. Breast feeding Amber Shephard
11/14/xx 11:30pm Delivered 23 year old
99. No lacerations.Normal vaginal delivery.
G2P1 NSVD 7 lb. 140z, female Apgars Female infant with Apgars of 9 and 9 in LOA.Estimate blood Inss: 300 ml. Afchrile Placenta delivered spontaneously.
Midline episiotomy with repaired with Ethilon.
Amber ShephardPainted Valley Antepartum testing
Sonography
Amniocentesis
Age under 16 or over 40 Gravida 1 with age 35-
Rh negative
Rubella exposure
Use of drugs:[D
History of High Risk Complications
Difficult labor, delivery or puerperium
Cesarean section
Stillborn or 3 or more abortions
Neonatal death
Live births under 5 pounds Toxemia or hypertensive disease
Immediate infant distress injury None
Diabetes mellitus
Genital infection
Urinary tract infection
Premature by dates
Over 2 weeks past FDC
Excessive weight gain None
4:25 pm
No
Obstetric Admission
Date
11/14/xx 125/60
Time
BP
Temp
98.8
20
Resp Induction
140)
yes yes
Lahor
No
Hour
Onsel 11/14 Date 0835 time 0800 time
Tast meal
11/14
Date
Membranes
intact
ruptured 165
Height
Weight
Other
Yes
consents
Signed
Condition:
Good
Fair
Critical
Gr
Para
L Ab 0 Stillborn
Blood Group 0
Rh Neg
LNMP
2/13/xx
LDC neg
Weeks Now 37
Prenatal visits Yes
No
Current Medications None
56"
None
Allergies
Previous Labor History Previous anesthetics
History of blood transfusions.
OK
Comments:
OK
time
initials
Prep
Enemar
5:15
LAB:
5:15
IV:
5:15
time
FT.
Antepartum testing
Sonography
Amniocentesis
Age under 16 or over 40 Gravida 1 with age 35-
Rh negative
Rubella exposure
Use of drugs:[D
History of High Risk Complications
Difficult labor, delivery or puerperium
Cesarean section
Stillborn or 3 or more abortions
Neonatal death
Live births under 5 pounds Toxemia or hypertensive disease
Immediate infant distress injury None
Diabetes mellitus
Genital infection
Urinary tract infection
Premature by dates
Over 2 weeks past FDC
Excessive weight gain None
4:25 pm
No
Obstetric Admission
Date
11/14/xx 125/60
Time
BP
Temp
98.8
20
Resp Induction
140)
yes yes
Lahor
No
Hour
Onsel 11/14 Date 0835 time 0800 time
.
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if you were transcribing this report- how would the appropriate and ac.docx
1. if you were transcribing this report, how would the appropriate and accurate use of obstetrical
terminology support the following in performing their jobs:
ICD-10-CM/PCS coders
Nurses
Physicians Painted Valley, USA
Montero, Elena C Dr. Amber Shephard 126 #706203
PREPARTUM STANDING ORDERS
1.
2.
3.
Check fetal heart tones and vital signs.
Urinalysis
CBC
4
Call physician.
Perineal prep Fleets or soft suds enema as ordered. h.
5.
7.
NPO except for ice chips.
8. 5% D/W in Labor Room. Infuse at 150cc/hour. 9. Notify physician of progress for sedation
order.
10. Apply fetal monitor.
11. May be up to shower if not in active labor,
bleeding, or fetal distress.
12. May administer oxygen at 10 liters per mask
2. for fetal distress then notify physician.
Amber Shephard
Delivery Room
11/14/xx
I 2 Pitucin U10 in IV after delivery of placenta. If no TV, Pitocin U10 IM.
Amber Shephard
11/14/xx S:31pm Adruit and follow routine
orders. Breast feeding Amber Shephard
11/14/xx 11:30pm Delivered 23 year old
99. No lacerations.Normal vaginal delivery.
G2P1 NSVD 7 lb. 140z, female Apgars Female infant with Apgars of 9 and 9 in LOA.Estimate
blood Inss: 300 ml. Afchrile Placenta delivered spontaneously.
Midline episiotomy with repaired with Ethilon.
Amber ShephardPainted Valley Antepartum testing
Sonography
Amniocentesis
Age under 16 or over 40 Gravida 1 with age 35-
Rh negative
Rubella exposure
Use of drugs:[D
History of High Risk Complications
Difficult labor, delivery or puerperium
Cesarean section
Stillborn or 3 or more abortions
3. Neonatal death
Live births under 5 pounds Toxemia or hypertensive disease
Immediate infant distress injury None
Diabetes mellitus
Genital infection
Urinary tract infection
Premature by dates
Over 2 weeks past FDC
Excessive weight gain None
4:25 pm
No
Obstetric Admission
Date
11/14/xx 125/60
Time
BP
Temp
98.8
20
Resp Induction
140)
yes yes
Lahor
4. No
Hour
Onsel 11/14 Date 0835 time 0800 time
Tast meal
11/14
Date
Membranes
intact
ruptured 165
Height
Weight
Other
Yes
consents
Signed
Condition:
Good
Fair
Critical
Gr
Para
L Ab 0 Stillborn
Blood Group 0
5. Rh Neg
LNMP
2/13/xx
LDC neg
Weeks Now 37
Prenatal visits Yes
No
Current Medications None
56"
None
Allergies
Previous Labor History Previous anesthetics
History of blood transfusions.
OK
Comments:
OK
time
initials
Prep
Enemar
5:15
LAB:
5:15
6. IV:
5:15
time
FT.
Antepartum testing
Sonography
Amniocentesis
Age under 16 or over 40 Gravida 1 with age 35-
Rh negative
Rubella exposure
Use of drugs:[D
History of High Risk Complications
Difficult labor, delivery or puerperium
Cesarean section
Stillborn or 3 or more abortions
Neonatal death
Live births under 5 pounds Toxemia or hypertensive disease
Immediate infant distress injury None
Diabetes mellitus
Genital infection
Urinary tract infection
Premature by dates
Over 2 weeks past FDC
7. Excessive weight gain None
4:25 pm
No
Obstetric Admission
Date
11/14/xx 125/60
Time
BP
Temp
98.8
20
Resp Induction
140)
yes yes
Lahor
No
Hour
Onsel 11/14 Date 0835 time 0800 time
Tast meal
11/14
Date
Membranes
intact
9. 56"
None
Allergies
Previous Labor History Previous anesthetics
History of blood transfusions.
OK
Comments:
OK
time
initials
Prep
Enemar
5:15
LAB:
5:15
IV:
5:15
time
FT.
initials
time
ET
initials
10. Social Data:
Language
English
Support System Husband, mother
Marital Status
M
Form 2919 (6703) Nsg Simmbad to Amore Holth Information Manage Aston All righteo
OBSTETRICAL ASSESSMENT
M
Form 2919 (6703) Nsg Simmbad to Amore Holth Information Manage Aston All righteo
OBSTETRICAL ASSESSMENT
