Assessing Patient’s Condition Precisely For Levelling OB Visits

Quality is gestational age. Quality is when the physician makes a statement in the record that size = equal dates, size < than date, size > date. This is the quality issue. The patient might describe that she feels puffy. That would be a quality issue. She might say she's crampy. That would be a quality issue.

n the case of the element of severity, generally it needs to be categorized by something. So she needs to say, it's not enough to say “I have pain”. Pain is a quality issue. Is there no fetal movement? Is there too much fetal movement? Things like that would be the severity index. So it's quantifying how bad is it.

Duration, her last monthly period, how long has she actually been pregnant? This is slightly different than gestational age which is the development of the fetus. This is actually physically how her body manages this one. How long have you been cramping? How long has this particular itch been going on? Has been in days, weeks, months, et cetera? You can pick these things out of the record quite easily.

Timing, generally, they're going to be referring to contractions. That would be the most common thing you would see on OB record. And so is he having contractions every two minutes? Is it every hour? Is it once a week that she's been having that? Or is she having pain? And how long or excuse me, what's the timing of that? “Well, every single week on a Monday when I do such and so I am having this particular pain.”

Context, okay, “I'm feeling this after I eat. When I bend over, something happens, after the baby moves, when I get up in the morning” any of those kinds of phrases will apply to the context of this chief complaint and what's happening around it.’

Modifying factors, okay, was she walking when it occurred? Was she sitting? Was she eating something? Was she drinking something? Does rubbing the area make it feel better? Does the drug they gave her, is it working? Is it not?

And so, again, you're thinking in terms of not only just her physical reactions. But you're pulling in things as well about what might also happen to the fetus and her reaction to that.
And then of course, we all know the famous associated signs and symptoms with pregnancy, nausea, vomiting, cramping, spotting. Those would be most of them or it might be diarrhoea or, you know, any of the above. So these are just some suggestions of things you might look for in that note.

Now, you have to have of course, to get a higher level of service, HPI is fine. But you've got to have a review of systems to go along with it. So how do we translate this into an obstetric situation? Well, the first thing comes to mind you do ten systems to be a complete review of systems.

Anytime you see a note where the physician says, “Patient denies” then whatever is listed afterward, you will count as a review of systems, okay? It's just kind of an automatic thing that you should think about.

So he may ask her. “Patient denies having any nausea, vomiting, cramping or spotting”, okay? As soon as you said that, you know you have a review of the GI and the GU system. But he might ask her about her current conditions. And remember, review of systems is what's going on now, not what happened in the past but what's going on now.