ob gyn patient care report

Solution: Report one unit of 59425 Antepartum care only; 4-6 visits, which represents the total services rendered by your ob-gyn. Sometimes, a payer may instruct you to report a separate E/M service for the first ob encounter.

Full Answer

What is a patient care report?

A patient care report is a document written by medical professionals to report about the patient’s wellbeing, care and status. This document consists of the result of the assessment and the evaluation of the patient being done by the EMTs or the EMS.

How many antepartum visits should an OBGYN see a pregnant patient?

Scenario: Your ob-gyn sees a pregnant patient for four to six antepartum visits. Solution: Report one unit of 59425 Antepartum care only; 4-6 visits, which represents the total services rendered by your ob-gyn.

What should be included in a gynecologic note-taking?

Include any important history such as hypertension, cancer, stroke, cardiac disease, diabetes. For gynecologic note-taking, pay careful attention to reproductive health cancers and their candidacy for genetic screening (BRCA, COLARIS).

Who can write reports in healthcare?

A lot of people believe that only nurses or health care workers can write reports. Most specifically patient care reports or anything that may be related to an incident report that often happens in hospitals or in some health care facilities.

What should a gynecological history include?

Menstrual historyLast menstrual period (LMP) - date of first day of bleeding.Cycle length and frequency - eg, 5/28, five days of bleeding every 28 days.Heaviness of bleeding. ... Presence or absence of intermenstrual bleeding (IMB).Presence or absence of postcoital bleeding (PCB).Age of menarche/menopause.More items...•

How do I access ACOG?

ACOG Fellows (U.S.) call 1-866-489-0443 b. ACOG Fellows (International) call 301-223-2300 c. Non-member subscribers (U.S.) call 1-800-638-3030 d. Non-member subscribers (International) call 301-223-2300 2.

What are the responsibilities of an OB-GYN?

OB/GYNs care for women during pregnancy, giving advice and performing tests such as ultrasounds and fetal heart rate monitoring to check on the health of the developing fetus and the mother. Obstetricians perform the delivery, and if necessary perform a surgical caesarean section.

What does ACOG mean?

American College of Obstetricians and GynecologistsThis website is powered by the American College of Obstetricians and Gynecologists (ACOG), the nation's leading group of physicians dedicated to improving women's health.

Is ACOG account free?

Medical student membership is complimentary. Annual dues will not be charged.

What is ACOG in pregnancy?

The American College of Obstetricians and Gynecologists Committee on Obstetric Practice Society for Maternal-Fetal Medicine.

What is the difference between OB-GYN and gynecologist?

Obstetricians do not treat health issues beyond pregnancy. Gynecologists, on the other hand, do not deliver babies or treat pregnant women. They instead focus on the health of the uterus, the ovaries, the fallopian tubes, and other organs of the female reproductive system.

How long do ACOGs last?

Most ACOGs do not use batteries for reticle illumination, being designed to use internal phosphor illumination provided by the radioactive decay of tritium. The tritium illumination has a usable life of 10–15 years.

What is Trijicon BAC?

Trijicon's Bindon Aiming Concept™ (BAC) feature allows the shooter to track and engage targets faster by utilizing an illuminated aiming point, instead of traditional black crosshairs.

Does ACOG support abortion?

As the leading medical organization dedicated to the health of individuals in need of gynecologic and obstetric care, the American College of Obstetricians and Gynecologists (ACOG) supports the availability of high-quality reproductive health services for all people and is committed to protecting and increasing access ...

What is the American College of Obstetricians and Gynecologists?

The American College of Obstetricians and Gynecologists continues to emphasize its long-standing commitment to quality and patient safety by codifying a set of objectives that should be adopted by obstetrician–gynecologists in their practices.

What is ACOG in obstetrics?

Obstetrician–gynecologists should continuously incorporate elements of patient safety into their practices and also encourage others to use these practices. The American College of Obstetricians and Gynecologists (ACOG) is committed to improving quality and safety in women’s health care. The Institute of Medicine report, ...

Why is informed consent important for patients?

According to the ACOG Committee Opinion, Informed Consent, the “involvement of patients in [decisions about their own medical care] is good for their health—not only because it is a protection against treatment that patients might consider harmful, but because it contributes positively to their well-being” 15. Patients should be encouraged to ask questions about medical procedures, the medications they are taking, and any other aspect of their care. Patient education materials developed by ACOG and other organizations are available.

What is communication in healthcare?

Communication between all members of the health care team is a crucial element in patient safety. In its analysis of sentinel events, the Joint Commission found that almost two thirds of the events involved communication failure as a root cause 8. Training in teamwork and communication techniques is increasingly being recognized as a cornerstone of a robust patient safety program; AHRQ developed the TeamSTEPPS™ program to address this issue 9. One key communication tool that it advocates is SBAR–Situation, Background, Assessment, and Recommendation or Request. It is a structured system to communicate critical information clearly and efficiently. It allows caregivers to provide information on what is happening to the patient, what the clinical background is, what they think the problem is, and what they would recommend or what action is being requested. This information can then be appropriately understood and acted upon.

What is a structured system?

It is a structured system to communicate critical information clearly and efficiently. It allows caregivers to provide information on what is happening to the patient, what the clinical background is, what they think the problem is, and what they would recommend or what action is being requested.

What is surgical error?

Surgical errors may involve the performance of the incorrect operation or a procedure on the wrong site or wrong patient. Although these errors occur much less frequently than medication errors, the consequences of these errors are always significant. The attending obstetrician–gynecologist who is ultimately responsible for the patient’s care should work with other operating room personnel, such as nurses and anesthesiologists, to be certain that systems are in place to ensure proper patient and procedure identification. The obstetrician–gynecologist also should use a preoperative verification process to confirm, with the patient, the intended procedure to be performed.

What is the type of behavior that puts patients at significant risk of harm and shows a conscious disregard of unreasonable risk?

At-risk behavior is the type of rule bending that tends to naturally occur over time in systems where the rate of adverse outcomes is very low. Reckless behavior is the type of behavior that clearly puts patients at significant risk of harm and shows a conscious disregard of unreasonable risk. In a just culture, instances ...

What stitches were used for the parietal peritoneum?

Once appropriate hemostasis had been achieved and the lap and instruments counts were reported as correct, the parietal peritoneum was approximated using #0 Vicryl continuous stitch, followed by approximation of fascia using Vicryl #1 continuous stitch in two segments. The skin was approximated with #4-0 Vicryl subcuticular stitch. The patient tolerated the procedure well and returned to the recovery room in good condition with Foley draining blue-colored urine.

What clamps were used to grasp the left and right ovaries?

At this time, Babcock clamps were used to grasp the left and right ovaries, and they were removed per the patient’s request. Curved Zeppelin clamps were placed across the infundibulopelvic ligaments bilaterally and curved scissors were used to excise the specimen from the Zeppelin clamp. The pedicles were doubly ligated bilaterally with 0 Vicryl and hemostasis noted to be achieved. No other abnormalities were noted in the pelvic cavity.

What ligaments were used in the Ligasure device?

The LigaSure device was then used in a serial fashion up through the cardinal ligaments bilaterally. Finally, the uterine arteries were cross-clamped, cut, and ligated with the LigaSure device. LigaSure device was then used up through the broad ligaments superiorly and finally the uterus was rotated posteriorly. The left and right tubes were then cross-clamped and ligated with LigaSure device. The uterus was excised and submitted for pathologic evaluation.

What was removed from the patient's abdominopelvic cavity?

At this time, instruments were removed from the patient’s abdominopelvic cavity. Vaginal cuff closure and peritoneum were incorporated into one layer with 0 Vicryl suture in a continuous running interlocking fashion. Hemostasis was noted to be achieved. Foley catheter was then placed yielding clear amber urine. A vaginal packing with Premarin cream was placed to provide support during the healing process. The patient tolerated the procedure well and was taken to the recovery room in a stable condition. Sponge and needle counts were correct x3.

How to cut a right round ligament?

The right round ligament was clamped with two Kelly clamps, cut with Metzenbaum scissors and suture ligated with #0 Vicryl. The anterior leaf of the broad ligament was cut using Metzenbaum scissors. The bladder that was adherent to the anterior aspect of the uterus was gently dissected using sharp and blunt dissection and it was gently pushed down with the sponge on a stick. Two fingers were inserted through the posterior leaf of the right broad ligament. The tissue was cut with Metzenbaum scissors and it was clamped using a straight Heaney clamp. Another clamp was placed medial to this. It was cut with Metzenbaum scissors. Sutures transfixed x2 using #0 Vicryl. The right uterine artery was then skeletonized, clamped at the level of the cervical os using a curved Heaney clamp. Another clamp was placed medial to this. It was cut with the Metzenbaum scissors and suture transfixed x2 using #0 Vicryl. Similar procedure was done on the opposite side.

What was the cord cut between the clamps?

The cord was doubly clamped, cut between the clamps, and the infant was handed away to the pediatrician. Cord bloods were taken. The placenta was then manually separated. The edges of the uterine incision were then reapproximated with continuous running suture of #1 chromic catgut.

How was the Pfannenstiel incision made?

A Pfannenstiel incision was made with a clean scalpel. The incision was taken down the fascial layer with a clean second knife. The fascial layer was incised transversely to the full length of the primary incision. The underlying muscle bellies were dissected with blunt and sharp dissection. The muscle belly was split in the midline. The peritoneum was then grasped between 2 Kelly clamps and elevated. After ensuring no adherent bowel or bladder, the peritoneum was nicked between clamps. The abdominal cavity was thus entered. The bladder flap was formed with blunt and sharp dissection and then the uterus was scored in the lower uterine segment in transverse fashion, and the incision was enlarged in elliptical fashion with bandage scissors. The infant was found to be in face presentation with nuchal cord x1. Mouth and nose were suctioned prior to delivery of rest of the body. The cord was slipped over the shoulders and then the infant was delivered. It was a living female with Apgars of 8 and 9. There was meconium, but it was not thick. Cord pH was 7.30. The cord was doubly clamped, cut between the clamps, and the infant was handed away to the pediatrician. Cord bloods were taken.

What is the general appearance of a patient?

General appearance: The patient is alert, oriented X 4, in no acute distress.

What does SH mean in nursing?

SH (Social/Personal History) Single, attending college PT for nursing, works FT as a waitress, no drug use, 5-7 glasses of beer per week before pregnancy (1-2 at one time). Has not consumed alcohol since 3/1/2015. Never smoker. Christian, non-denominational No domestic violence. Does not have a cat, no litter box. Personal – Denies History of abuse, mental illness, depression, anxiety, or eating disorders.

What does CC mean in PT?

CC: Unintended pregnancy, pt is accepting but overwhelmed. Unmarried, FOB involved. Presenting for OB care as a new patient, first antepartum visit.

What is a family history?

Family History (FamHx): Interview the patient about mom, dad, siblings, and grandparents on both sides. Include any important history such as hypertension, cancer, stroke, cardiac disease, diabetes. For gynecologic note-taking, pay careful attention to reproductive health cancers and their candidacy for genetic screening (BRCA, COLARIS).

What is HPI medical?

History of Present Illness (HPI): All medical information relevant to today's particular complaint. Think about their current situation and any other pertinent data.

What is subjective data?

Subjective data is the description that the patient gives you. It cannot be measured.

What is a soap note?

The SOAP note is an essential method of documentation in the medical field. It's imperative that every student learn the basics for writing a SOAP note to become a health care provider like a physician or an Advanced Practice Nurse.

What Is a Patient Care Report?

We often hear of care reports based on by medical teams or by medical authorities. Yet, we are not sure how this differs from the kind of report that is given to us by the same people. So this is the time to make it as clear as possible.

How to Write a Patient Care Report?

Where do you even begin when you write a patient care report? A lot of EMS or EMTs do know how to write one since they are trained to do so.

What is a patient care report?

A patient care report is a document made mostly by the EMS or EMTs. This documented report is done after getting the call. This consists of the information necessary for the assessment and evaluation of a patient’s care.

What should not be written in a patient care report?

What should be avoided in a patient care report is making up the information that is not true to the patient. This is why you have to be very careful and very meticulous when writing these kinds of reports. Every detail counts.

Who is in charge of reading the patient care report?

The person or the people who will be reading the report are mostly medical authorities. When you are going to be passing this kind of report, make sure that you have all the information correctly. One wrong information can cause a lot of issues and problems.

What is the Medicare code for antepartum follow up?

Second and third visits: When Medicare and American College of Obstetricians and Gynecologists (ACOG) were developing the relative value units for antepartum care, the follow-up visit was estimated to be 99213 Office or other outpatient visit for the evaluation and management of an established patient … 20-29 minutes of total time is spent on the date of the encounter. This code is still your best bet for each of these visits in the absence of documented problems.

What does open enrollment mean in OB-GYN?

Open enrollment means that you may have patients returning to your ob-gyn practice in various stages of their pregnancy with different insurance companies. CPT® clearly states that when all or part of the antepartum and/or postpartum patient care is provided (except delivery due to termination of pregnancy by abortion or referral to another provider ...

What is the diagnosis code for OB encounter?

The diagnosis code will be the same (Z34.0- Encounter for supervision of normal first pregnancy or Z34.8- Encounter for supervision of other normal pregnancy) unless the patient has any problems or complications.

How long is the first OB visit?

First visit: For the first obstetrics (ob) visit, don’t automatically look at 99214 Office or other outpatient visit for the evaluation and management of an established patient … 30-39 minutes of total time is spent on the date of the encounter. The patient could be new to the practice, or the first visit may meet level 5 criteria or only level 3 established visit criteria.

Why avoid reporting global package codes?

Solution: Avoid reporting the global package codes since the patient will not have delivered during the time insurance ‘A’ is responsible for payment.

How many prenatal visits are reported in 59426?

Keep in mind that 59426 is valued based on the assumption that it includes a maximum of 10 visits. If the number of actual visits exceeds this, modifier 22 Increased procedural services might be appropriate, provided the documentation supports significant additional work.

Who is Suzanne Burmeister?

She is managing editor at The Coding Institute and is the go-to resource for the toughest obstetrics and gynecology (ob-gyn) coding questions . Burmeister has been the Ob-Gyn Coding Alert editor since 2004. She has a Bachelor of Arts degree from North Carolina State University and an international master’s degree from Trinity College Dublin.