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.
Training Material for All Users
OB/Lactation Training Slides
*Intended for classroom use
OB/Lactation Paper Backup
OB/Lactation User Guide
*Intended for individual use
OB Encounter Worksheets
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
- 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.
TSWF-OB/Lactation Form Lead
Samuel P. Eng, M.D.,M.S.,FAAFP
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