The TSWF OB/Lactation AIM form is intended to provide family medicine and obstetrics physicians a standardized template with elements important to antepartum and postpartum outpatient care.

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OB/Lactation Recent Changes

  • 22 changes for Jan-Apr 2019 update
  • Replaced text next to GC ‘(when indicated)’ to ‘(weeks 10-12)’ on the ‘Initial and supplemental labs and u/s’ free text section.
  • Changed nomenclature of the heading ‘Maternal Postpartum Depression Screen’ to ‘Maternal Depression Screen’.
  • Simplified the appearance of the EPDS Score in the form and how it emits in the Note View. On both the Screening and Postpartum Visit tabs.
  • Adjusted the Annual Question from “Learning disability, language barrier, hearing/vision deficit” to Learning disability, language or emotional barrier, hearing/vision deficit?”
  • Added question ‘is patient able, motivated, and willing to learn about their healthcare?’ With yes and no documentation
  • Added “Are you enrolled in Secure Messaging __Yes __No ” to the Annual Questions field
  • Updated Zika clinical clue to “Women of childbearing age and men”
  • Updated Intimate Partner Violence clinical clue “Women of childbearing age” , done, check sizing “follow local”
  • Added a clinical clue to all forms on the HPI tab directly above the Medical Conditions and Surgeries/Procedures: “Document anatomic or functional asplenia as surgical history or medical condition AND add diagnosis code(s) in A/P if needed.”
  • Added clinical clue ‘IAW MEDCOM Policy Memo 17-035, initial assessment of each patient using both SILS and REALM-SF; for subsequent assessments use SILS annually and REALM-SF according to local policy.’ to ‘Annual Questions’ field.
  • Added a new copy-forward specific field entitled “Occupational history and exposures” to the TSWF CORE family of forms. With a clinical clue “(also military duty-related information)”.
  • Updated the “Social History” field clinical clue to say “Family and lifestyle issues”
    Removed “Other Military Duty-Related Information” check box.
  • Added clinical clue ‘Include military duty-related info’ in new Occupational History field
  • Updated Allergy clinical clue
  • Updated Tobacco Cessation Counseling
  • Added Thinking about Quitting Tobacco Cessation link
  • Added clinical clue “If appropriate, for provider-delivered counseling use additional E&M code 99406 for duration of 3-10 minutes, 99407 for duration >10 minutes” to Tobacco cessation counseling
  • “Added “DoD/VA Pain Rating Scale: pain severity = /10.”
  • Changed DVPRS clinical clue to “If >4, open ribbon to document functional impact.”
  • Moved “Pain Assessment” field to DVPRS ribbon (except for LOT)
  • PHQ-9 New format and auto calculates

History

  • Developed for antepartum care and postpartum care
  • This template matured to include elements of the VA/DoD Guidelines
  • Updated three times a year

This AIM form grew out of a need to develop a standardized workflow for antepartum and postpartum care in the outpatient setting. The nascent form of this template grew from Family Medicine residences as a means to embed essential elements in the primary care setting, and matured to include elements of the VA/DoD guidelines. More recently, elements of lactation have been included to standardize documentation for this specialty during postpartum care.

Form Lead

TSWF-OB/Lactation Form Lead
Samuel P. Eng, M.D.,M.S.,FAAFP

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