INITIAL ASSESSMENT OF LEARNING CHALLENGES OF PATIENT/FAMILY:

No barriers identified.

LEARNING PREFERENCES: Both written and verbal explanations.

* is a *-year-old * female. G*T*P*A*L*. Last menstrual period was * and was *. This gives her
an EDC of * which makes her * weeks pregnant. She presents today to maternity counseling for
an 0B workup. She has had a positive pregnancy test at home which is confirmed today at our
lab. Patient states pregnancy was *. Patient is * about this pregnancy. Significant other is *.

REVIEW OF SYSTEMS: Current symptoms include *. Denies history of blood transfusions,

infectious diseases, blood dyscrasias, or thromboembolic disease. Denies history of
gastrointestinal, liver, kidney, or cardiac disease. No history of reaction to anesthetic agents. She
* wear contact lenses.

For current pregnancy, see CPN. Denies history of hemorrhoids, varicosities, or leg cramps. No
exposure to x-rays or infections. No risk factors or toxoplasmosis exposure.

PREVIOUS PREGNANCY HISTORY: *

OBSTETRIC/GYNECOLOGIC HISTORY:

Periods are *. Last Pap smear was *. Contraception history is

Denies problems with dysmenorrhea, dysfunctional bleeding, severe nausea/cramping or PMS

associated problems with menses. Denies history of abnormal Pap smears, cervical disease or
surgery, DES exposure, breast cancer, sexually transmitted diseases, toxic shock syndrome,
pelvic inflammatory disease, or problems with infertility.

PAST MEDICAL HISTORY: Significant for *. The patient * chicken pox. Last TB skin test was
* and was *.

PAST SURGICAL HISTORY: Significant for *.

IMMUNIZATIONS: See EMR for more details. Last tetanus was *

ALLERGIES: *.

CURRENT MEDICATIONS: Medication list is updated in EMR.

FAMILY HISTORY: Significant for *

RELIGION: *

VITAL SIGNS: Pre-pregnancy weight *. Today's weight *. Height *.

PATIENT PROFILE: * is * and lives with * who * supportive of the pregnancy. She is

*. She * tolerating her job. She * tolerating her pregnancy well. * is

employed at * as a

employed at * as a *. Education level completed by patient *, significant other * The patient's

caffeine intake is *, Exercise/heavy labor consists of *. Smoking *. First

* * for abuse, rape, or sexually transmitted diseases

Breath *. Street drugs *. Alcohol *. Seat belt use

LABORATORY: The patient's initial prenatal lab work was ordered which includes a CBC,
prenatal profile, HIV, TSH, hepatitis B, and urine.

PREGNANCY RISK FACTORS: Significant for She * on a special diet at this time.
MATERNITY COUNSELING OBSTETRICAL WORKUP TEACHING: Per protocol.

CURRENT KNOWLEDGE ASSESSMENT: Understands objective/has necessary skills for self-

management.

READINESS TO LEARN/BARRIERS TO LEARNING: Accepting.

TEACHING METHODS: Verbal discussion and printed material.

OUTCOMES AND REINFORCEMENTS: Patient verbalizes understanding.

Patient will return for her next doctor appointment with * on *. With the assistance of the clinical
staff the patient will be scheduled for 28 and 36-week Maternity Counseling sessions.