Prenatal Record Template

Obstetric care is billed as a package rather than a visit, which makes the prenatal record different from every other note in medicine. Page one is the initial obstetric visit: pregnancy dating and EDD, G/P with TPAL, medical, family and social history, a risk assessment that drives visit frequency, baseline screening including perinatal depression and anxiety, and the examination and plan. Page two is a 13-row return-visit flow sheet with columns for date, weeks of gestation, weight, blood pressure, fundal height, fetal heart tones, urine, and findings.

The part that protects the claim is the package tracker. Routine antepartum care is usually about 13 visits, and if your group does not provide all of them, because the patient transferred, was referred, changed insurer, or miscarried, the pregnancy does not bill as a global package at all. It bills as 59426 for seven or more antepartum visits, 59425 for four to six, or itemized E/M visits for one to three. The template counts visits as you go and prompts for what was separately reported, since ultrasound, non-stress tests, amniocentesis, labs, and any care unrelated to the pregnancy sit outside the package. The page also prints what is inside the package so it does not get billed twice. Optimized for use with Sully.ai's AI medical scribe, it helps streamline note-taking and improve clinical efficiency.