Initial Evaluation: (the Initial evaluation section needs to be written in sentences and paragraphs) [name and Gestation] (always include first name, never say patient in this section) [Include if appointment is routine or acute] [how are they feeling since last appointment with midwife] [who is present at appointment] (include names of those present) [include recent activities (for instance, holidays or movies attended, activities with other friends and family)] [Include updates from previous appointments, for example pregnancy-related appointments] [Include mention of any pets, what they are and their names](personalize this section) (only include Include information if mentioned if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely)
Physical Examination:
- [BP] (only include BP if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- [Urinalysis results] (only include Urinalysis if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- [Palpation] (include position, lie, presentation, fundal height) (only include Palpation if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- [Fetal Heart] (only include Fetal Heart if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- [Movement history] (only include Movement history if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- [Growth chart] (Be specific about details of growth chart) (only include Growth chart if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- [CTG results] (include baseline fetal heart, accelerations, variability, decelerations (only include CTG if this has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- [Reflux, nausea, vomiting] (only include Reflux. nausea and vomiting if they have been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- [Current medications] (only include Current medications if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- [Symptoms of Preeclampsia or PET] (only include Symptoms of Preeclampsia or PET if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- [Vaccinations] (only include Vaccinations if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- [Any abnormal symptoms] (Mention headaches, visual disturbances, increased oedema, epigastric pain, symptoms of general unwellness) (only include Any abnormal symptoms, concerns if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Blood and Imaging Results:
- [Include all recent blood results if mentioned] (only include Include all recent results if mentioned if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- [Include all recent scan results] (only include Include all recent results if mentioned if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Medications:
- [current medications] ) (only include Include medications if they have been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- [New medications started] (Only mention new medications if specifically mentioned in transcript)
- [Prescriptions] (Only mention new prescriptions if specifically mentioned in transcript)
Emotional/Social:
- [how they are feeling and coping with pregnancy] [concerns about care receiving] (only include mention how they feel and cope with pregnancy if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- [their mood] (only include their mood if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- [their feelings about the baby] (only include their feelings about the baby if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- [family relationships]
- [whether they are getting out of the house and meeting up with friends] (only include whether they are getting out of the house and meeting up with friends if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- [Work, include when they are planning to go on maternity Leave] (only include Work and maternity leave if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Preparation for Baby:
- [colostrum harvesting] (only include Include colostrum harvesting if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- [purchases] (only include purchases if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- [car seats] (include did they hire or buy) (only include car seats if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- [clothing] (only include clothing if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- [nappies] (only include nappies if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- [room] (only include room if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- [Extra supports] (include any referrals to different agencies, for example, Family Start, Oranga Tamariki, Maternal Mental Health, GP, Physiotherapy, Lactations consultant) (give brief reason for the extra support (only include Extra supports if they have been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- [Family Supports]
Education:
- [Relevant topics such as safe sleep, side sleeping, and attendance at antenatal courses] (only include Relevant topics such as safe sleep, side sleeping, and attendance at antenatal courses if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Referrals:
- [All referrals to relevant practitioners] (Consultant Obstetrician, Physiotherapy, Dietician, Diabetes Nurse (only include All referrals to relevant practitioners if they have been explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise, omit completely.)
Birth Plan:
- [include Vitamin K IM or oral, consent for Vitamin K, skin to skin, delayed cord clamping, whose cutting the cord, breastfeeding plan, pain relief options, Placenta disposal, Use of TENS, Monitoring of baby, Home birth or Hospital Birth, Music list, environment, (put into bullet points)] (Do not include anything that was not in the Transcript)
- [When to call the Midwife for Labour]
Plan:
- [Future plan (include future appointments with other practitioners, include future scans, Include future blood tests)] (only include the future plan if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- [next appointment] (only include the next appointment if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
(Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information include in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely.) (Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.)