Federal Employee Program (FEP) PPO Networks Proper Documentation of Obstetrical Care

Oct. 29, 2018

Communication between health care professionals during the course of a patient’s pre-pregnancy, pregnancy, and postpartum medical journey is important. It is recommended that when caring for the patient, the following be documented in the patient’s chart to ensure effective coordination and continuity of care:

  • Prenatal Visit in First Trimester:
    • Prenatal risk assessment with counseling to include education, complete medical and obstetrical history, physical exam (e.g. ACOG Form)
    • Prenatal lab reports (OB panel/TORCH antibody panel/Rubella antibody test/ABO/ Rh)
    • Ultrasound, EDD
  • Duration of Prenatal Visits:
    • Prenatal flow sheet (ACOG, EMR, or other)
    • All progress/visit notes for duration of pregnancy
    • Ultrasound reports and all consult reports
  • Delivery:
    • Documents, such as hospital delivery records, verifying member had a live birth
    • If the patient had a non-live birth, records that document the non-live birth
  • Postpartum:
    • Documentation of a postpartum visit on or between 21-56 days after delivery
    • Postpartum office visit progress notation that documents an evaluation of weight, blood pressure, breast exam, abdominal exam, and pelvic exam

Thank you for your partnership with us in the care of Blue Cross and Blue Shield Service Benefit Plan members.