Wiki Delivery note requirements

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lhoney7181

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Hello,

Does the delivery note have to have a narrative included? I am getting kick back from a manager that 'everything is in the headings', and I told her I need a narrative to select the correct procedure code. I cant find any guidelines for documentation of a NSVD. Does anyone have a reference I can produce, as she wont take my word for it. Thank you in advance!
 
What do you mean by headings? Are you talking about vaginal delivery ? I have pasted below a fairly standard example although some providers write a note.
Here's a link from ACOG with some info https://www.acog.org/practice-manag...mentation-requirements-for-vaginal-deliveries

Delivery Note

xxx is a 39 year old now G3P2012 female post-delivery at 40w3d. Pregnancy was significant for AMA, marginal cord insertion, routine prenatal care and Labor.

Mother's Information
Labor Length
1st stage: 3h 32m
2nd stage: 0h 08m
3rd stage: 0h 04m

Lacerations
Episiotomy: None
Perineal laceration: 2nd Degree
Perineal laceration repaired?: Yes
Repair suture: 3-0 Vicryl

Delivery Blood Loss 10/07/23 1100 - 10/07/23 1510
QBL: Vaginal Delivery Volume Hospital Encounter 250 ML
Total 250


xx, Boy xx
Newborn Delivery
Time head delivered: 10/7/2023 14:40:00
Birth date/time: 10/7/2023 14:40:00
Delivery type: Vaginal, Spontaneous
Complications: None

Labor Events
Preterm labor?: No
Rupture date/time: 10/7/2023 1329
Rupture type: Artificial
Fluid color: Clear
Fluid odor: Normal
Labor type: Spontaneous Onset of Labor
Labor allowed to proceed with plans for an attempted vaginal birth?: Yes
Augmentation: AROM
Augmentation date/time: 10/7/2023 1329
Complications: None

Anesthesia
Method: Local

Operative Delivery
Forceps attempted?: No
Vacuum extractor attempted?: No

Shoulder Dystocia
Shoulder dystocia present?: No

Presentation
Presentation: Vertex
Position: Direct Occiput Anterior

Placenta
Placenta delivery date/time: 10/7/2023 1444
Placenta removal: Spontaneous
Placenta appearance: Intact
Placenta disposition: discarded

Cord
Vessels: 3 Vessels
Complications: None
Delayed cord clamping?: Yes
Cord clamped date/time: 10/7/2023 1441
Cord blood disposition: Discard
Gases sent?: No
Stem cell collection (by provider): No

Apgars
Living status: Living
Apgar Component Scores: 1 min.: 5 min.: 10 min.: 15 min.: 20 min.:
Skin color: 0 1
Heart rate: 2 2
Reflex irritability: 2 2
Muscle tone: 2 2
Respiratory effort: 2 2
Total: 8 9
Apgars assigned by: xx

Resuscitation
Method: None

Measurements
Weight: 4180 g
Weight (lbs): 9 lb 3.4 oz
Length: 55.9 cm
Length (in): 22"
Head circumference: 36 cm

Delivery Providers
Delivering clinician: xx, MD
Provider Role
xx, RN Delivery Nurse
xx Tech
xx Baby Nurse
 
Cmama12 said:
What do you mean by headings? Are you talking about vaginal delivery ? I have pasted below a fairly standard example although some providers write a note.
Here's a link from ACOG with some info https://www.acog.org/practice-manag...mentation-requirements-for-vaginal-deliveries

Delivery Note

xxx is a 39 year old now G3P2012 female post-delivery at 40w3d. Pregnancy was significant for AMA, marginal cord insertion, routine prenatal care and Labor.

Mother's Information
Labor Length
1st stage: 3h 32m
2nd stage: 0h 08m
3rd stage: 0h 04m

Lacerations
Episiotomy: None
Perineal laceration: 2nd Degree
Perineal laceration repaired?: Yes
Repair suture: 3-0 Vicryl

Delivery Blood Loss 10/07/23 1100 - 10/07/23 1510
QBL: Vaginal Delivery Volume Hospital Encounter 250 ML
Total 250


xx, Boy xx
Newborn Delivery
Time head delivered: 10/7/2023 14:40:00
Birth date/time: 10/7/2023 14:40:00
Delivery type: Vaginal, Spontaneous
Complications: None

Labor Events
Preterm labor?: No
Rupture date/time: 10/7/2023 1329
Rupture type: Artificial
Fluid color: Clear
Fluid odor: Normal
Labor type: Spontaneous Onset of Labor
Labor allowed to proceed with plans for an attempted vaginal birth?: Yes
Augmentation: AROM
Augmentation date/time: 10/7/2023 1329
Complications: None

Anesthesia
Method: Local

Operative Delivery
Forceps attempted?: No
Vacuum extractor attempted?: No

Shoulder Dystocia
Shoulder dystocia present?: No

Presentation
Presentation: Vertex
Position: Direct Occiput Anterior

Placenta
Placenta delivery date/time: 10/7/2023 1444
Placenta removal: Spontaneous
Placenta appearance: Intact
Placenta disposition: discarded

Cord
Vessels: 3 Vessels
Complications: None
Delayed cord clamping?: Yes
Cord clamped date/time: 10/7/2023 1441
Cord blood disposition: Discard
Gases sent?: No
Stem cell collection (by provider): No

Apgars
Living status: Living
Apgar Component Scores: 1 min.: 5 min.: 10 min.: 15 min.: 20 min.:
Skin color: 0 1
Heart rate: 2 2
Reflex irritability: 2 2
Muscle tone: 2 2
Respiratory effort: 2 2
Total: 8 9
Apgars assigned by: xx

Resuscitation
Method: None

Measurements
Weight: 4180 g
Weight (lbs): 9 lb 3.4 oz
Length: 55.9 cm
Length (in): 22"
Head circumference: 36 cm

Delivery Providers
Delivering clinician: xx, MD
Provider Role
xx, RN Delivery Nurse
xx Tech
xx Baby Nurse
Click to expand...
I guess I need clarity on the 3rd bullet of the ACOG requirements. It says details of the procedure, I take this as a narrative? Just like in an op note, we have to code from the narrative only. Thank you kindly, CMAMA!
 
lhoney7181 said:
I guess I need clarity on the 3rd bullet of the ACOG requirements. It says details of the procedure, I take this as a narrative? Just like in an op note, we have to code from the narrative only. Thank you kindly, CMAMA!
Click to expand...
No, I don't think that's what it means. First of all it says to follow facility guidelines and if you don't have those, then it is giving examples of information that would be relevant to include, hence the "such as" It is not saying you need all of these.

When facility documentation guidelines do not exist, the delivery note should include patient-specific, medically or clinically relevant details such as

  • Maternal–fetal assessment prior to delivery
  • Labor details, eg, induction or augmentation, if any
  • Details of the procedure, indications, if any, for OVD
  • Maternal status after the delivery
  • Complications, if any
  • Blood loss
  • Newborn status
 
Cmama12 said:
No, I don't think that's what it means. First of all it says to follow facility guidelines and if you don't have those, then it is giving examples of information that would be relevant to include, hence the "such as" It is not saying you need all of these.

When facility documentation guidelines do not exist, the delivery note should include patient-specific, medically or clinically relevant details such as

  • Maternal–fetal assessment prior to delivery
  • Labor details, eg, induction or augmentation, if any
  • Details of the procedure, indications, if any, for OVD
  • Maternal status after the delivery
  • Complications, if any
  • Blood loss
  • Newborn status
Click to expand...
We don't have specific OB/GYN facility guidelines, just IN and Outpatient. Thank you for your time, much appreciated!
 
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