HIVE Antepartum List
DATE
PG. 1 BLANK TEMPLATE – DO NOT FILL WITH PATIENT INFO
Labs:
Age yo Gx Px
Patient name:
Date
Problem List:
MRN:
CD4(%)
1. HIV:
VL
DOB:
 Date of dx, CD4, VL
Gest age by
L=week US on
x/x/x
Final EDD: x/x/x by US
on date
LMP: (sure/unsure)
LMP EDD:
Dating sono on date: GA
xwxd, sono EDD x/x/x.
Final EDD: x/x/x by xw
US on date
1st BAPAC visit:
Most recent visit:
Next visit:
Patient contact info:
Primary care
provider:
Pharmacy:
1-415- phone
1-415- fax
Peds follow-up:






Confirmed
ART history
CD4 nadir
HIV genotype
HLAB5701
OI, hospitalization hx
2.
POBH:
3.
Social hx (partner, kids, living situation):
4.
Delivery Plan:
5.
Contraceptive Method:
6.
Research protocols: study number,
eligible/ineligible, date enrolled, date next
study visit
Hct
Plt
MCV
AST/ALT
BUN/Cr
Other
Baby
ruleout
Prenatal labs:
1st tri: date
ABORh
RPR
Rubella
HAV Ab
HBSAg
HBSAb
HBCAb
HCV Ab
HCV VL
HLAB5701
GC
CT
Wet prep
3rd tri: date
1hr
GLT
3hr
GLT
RPR
ABORh
GC
CT
TO DO:
 [ ] Give welcome packet
 [ ] Prenatal intake RN visit
 [ ] APR registry: fax
registration and med form to
enroll new patient
 [ ] ANTC at 32 weeks for
HIV+
 [ ] 36 week post-partum
anticipatory guidance visit
Other
Early
1hr
GLT
Toxo
CMV
HSV
PPD
CXR
Lipids
VZV
HgbEP
G6PD
Wet prep
POSTPARTUM:
Allergies:
Doula Discussion:
HPP referral:
Meds:
Start
ARV
ARV
ARV
PNV
Cerv Pap
GBS
Anal Pap
Utox
Urine cx
Sonos:
00/00/17: Dating sono – EGA, whether c/w menstrual dating
00/00/17: Anatomy scan – EGA, placental location, presentation, EFW
w/ percentile, any anomalies, other pertinent info
Genetics:
1st trim screening – 11+2-14+2 weeks. NT result, serum results
2nd trim screening – 15+0-20+0 weeks. Serum results
Amnio Vaccines:
Up-to-date
Need to give
Flu
Pneumo: date
Tdap: date
HepB: date
HepA: date
Italicize past meds
Stop