The element in the history component for an evaluation of management service is relevant history. So for past history, we have what was her past obstetric history. We need to know what other diseases and surgery she had. We need to know her current medications. We need to know if she's allergic to any particular subject.
Now, remember that a listing of her allergies, the things that she is allergic to is not the same thing as a review of systems for allergies when you are asking or does she currently have a problem with them. So that would be part of relevant history. And that fits perfectly and with the current documentation guidelines. That's usually not an issue.
Every OB patient is asked some information about her genetic history. Are there any problems with the family, with diseases that might have been genetic in nature? And that will be in the charts of family history is usually not an issue at all in at least for the first visit; it's almost always on the chart.
Social history, what's her marital status. Is she smoking? Does she use alcohol? What's her current employment? Those are kinds of things you can ask her. She's pregnant but is she currently having sex with her husband or not? So that would all be pertinent to the reason for the visit that day.
And then we come to the relevant examination. Well, many, many years of looking at these and having audited gazillion of these OB records, the conclusion is that the 1995 exam documentation guidelines will get you the highest level of examination possible for any OB visit.
If you look at the data elements for the 1997 where you have to just pull bulleted elements generally speaking, you end up with a problem focused exam because we don’t have three vital signs normally being taken in most cases. We have blood pressure being taken. And sometimes temperature isn't recorded or anything else.
So frequently enough, this is not an issue. And the fetus’ heart rate is not a vital sign. It is an examination of the cardiovascular system. So, you're not even going to get the constitutional bullet in most cases.
Most physicians don’t make a comment on her general appearance unless she's really, really draggy and it’s noticeable. So that is hard to come by. But in the ‘95 guidelines, you have more freedom because you can use the combination of body areas in organ systems. And it is very easy to get an expanded problem focused exam using those 1995 guidelines.