Clinical Documentation Tip Sheets

Obstetrics/Gynecology This tip sheet is designed to assist physicians in accurately assessing and documenting the severity of illness in hospitalized patients within the electronic medical record (EMR).

PRENATAL CARE

MATERNAL RISK FACTORS

HYPERTENSIVE DISORDERS OF PREGNANCY

> Nutrition/Weight-related: Underweight: Pregravid BMI <19, Low weight gain in pregnancy, Obesity: Pregravid BMI >30, Malnutrition: Specify severity (e.g., moderate or severe) > Diabetes: Document type (e.g., gestational, preexisting Type 1 or 2). Specify manifestation (e.g., hypoglycemia, hyperglycemia). Note treatment (e.g., diet, oral medication, insulin)

> Gestational HTN

> Preeclampsia/Eclampsia: Specify if superimposed on preexisting hypertension. Identify onset. Specify acuity (eg, mild, moderate, severe). Include supportive clinical findings (e.g., severe range BPs, elevated PC ratio, AKI) > HELLP Syndrome: Document associated comorbid diagnoses: Coagulopathies, Hyperbilirubinemia,

> Epilepsy

> Maternal cardiac disease

> Document when present: spotting, uterine size, fetopelvic/cephalopelvic disproportion, chronic disease, shortened cervix, History of preterm labor, Multiple gestations POSTNATAL CARE > Specify postpartum conditions: Infections (eg, UTI, mastitis, chorioamnionitis): identify “Present on Admission”status, Lacerations: specify degree, Retained placenta , Postpartum hemorrhage & coagulopathies, Postpartum fever, Urinary retention, Bowel obstruction or ileus, Acute blood loss anemia > Uterine Atony Specify whether patient met criteria for PPH. Atony with ANY amount of bleeding codes to PPH Example: “Bleeding d/t uterine atony treated w/ Pitocin and uterine massage, not meeting clinical criteria for PPH at this time – EBL 550mL”

DELIVERY/SURGERY

> Document the following findings when present:

> Fetal: Abnormal fetal heart rate and rhythm, Decreased fetal movement > Umbilical cord: Cord prolapse, cord entanglement, short cord, velamentous insertion, nuchal cord > Placenta: placenta previa, placental abruption > Uterus: acquired or congenital uterine findings, e.g., Submucous fibroid, polyps, Arcuate uterus, T-shape uterus, Unicornuate uterus, Bicornuate uterus, Septate uterus, Uterus didelphys

> Presence of meconium

> Adhesions: Specify when adhesions significantly interfere w/ access to operative site