Wiki Documentation - prenatal visit

KoBee

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having trouble to figuring out if this is enough documentation for an E/M and to distinguish correct diagnosis.

20 were 21-year-old G5, P1 aborta 3 currently 34 weeks pregnant EDC 526 has not gained any weight at all this visit her blood sugars are normal fasting 73 and 1 hour 125 fetal heart tones are heard normally and we will see her back in 2 weeks for a follow-up

Prenatal Vitals
BP 109/73
Weight 213 lb 6.4 oz (96.8 kg)
Urine Albumin/Glucose
Urine Albumin Negative
Urine Glucose Negative
 
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