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Wiki OB Delivery OpReport

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KoBee

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Does anyone happen to know if this is enough for a Delivery Report



Result Type:
Procedure Note

Result Date:
May 07, 2022 2:52 PDT

Result Status:
Modified

Result Title/Subject:
Free Text Note

Performed By/Author:
XXX on May 07, 2022 2:52 PDT

Verified By:
XXXXX on May 07, 2022 2:54 PDT

Encounter info:
XXX, XXX, Inpatient, 5/6/2022 - 5/8/2022




SVD- intact perineum- placenta entire= ROA

EBL 300

Count correct -counted with MA



Signature Line
Electronically Signed By: XXXXX MD
On: 05.07.2022 02:54 PDT

Electronically Signed On: 05.07.2022 02:55 PDT
XXXXXx MD
 
Kobee
No this is improper for a ObGyn delivery note. Doctor needs to describe pt , give race, age, sex of delivery baby, did she have incision C section or natural birth, ETC. Does pt have any ongoing chronic conditions'? Need to spell out abbreviations and dx code. I would not accept this as proper documentation for delivery of baby! Also if ins company wanted a report...it be a payback .Horrible documentation!
Lady T
 
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