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Name:
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Elective: |
If Extramural or IDE, enter
identifying information here:
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Elective End Week: |
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Date Patient Seen: |
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Patient's Gender:
Female
Male
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Patient's Age:
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Location:
Clinic
OR
L&D
ER
Other
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Presenting Complaint 1:
(select
one) |
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*None
Abortion
(any type)
Abnormal labor
Abnormal
uterine bleeding
Amenorrhea/Oligomenorrhea
Antepartum care
Breast disorder
Cervical disease
Cervical neoplasia
Contraception/Sterilization
Dysmenorrhea
Ectopic pregnancy
Endometrial carcinoma
Endometriosis
Fetal death
Fetal growth abnormalities
Fetal surveillance
Genetic & heredity concerns
Gestational trophoblastic neoplasia
Hirsutism and Virilization |
Hyperglycemia/Diabetes Mellitus
Immediate care of the newborn
Infertility
Isoimmunization
Intrapartum care
Issues
of Bad News
Lactation
Medical & surgical conditions in pregnancy
Menopause
Modes of sexual expression
Mood Disorder
Multifetal gestation
Ovarian neoplasms
Pelvic pain
Pelvic relaxation
Postpartum care
Postpartum hemorrhage
Postpartum infection
Postterm pregnancy
Preconception care |
Pre-eclampsia/eclampsia syndrome
Premature rupture of membranes
Preterm labor
Preventive health care & health maintenance
Puberty
Sexuality
Sexual assault/domestic violence
Sexually transmitted disease
Sterilization
Spontaneous abortion
Substance abuse
Surgical complication
Third-trimester bleeding
Thromboembolic disorder
Urinary incontinence
Urinary tract infection
Uterine leiomyoma
Vulvar or vaginal disease/disorder
Vulvar neoplasm |
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Presenting Complaint 2:
(select
one) |
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*None
Abortion
(any type)
Abnormal labor
Abnormal
uterine bleeding
Amenorrhea/Oligomenorrhea
Antepartum care
Breast disorder
Cervical disease
Cervical neoplasia
Contraception/Sterilization
Dysmenorrhea
Ectopic pregnancy
Endometrial carcinoma
Endometriosis
Fetal death
Fetal growth abnormalities
Fetal surveillance
Genetic & heredity concerns
Gestational trophoblastic neoplasia
Hirsutism and Virilization |
Hyperglycemia/Diabetes Mellitus
Immediate care of the newborn
Infertility
Isoimmunization
Intrapartum care
Issues
of Bad News
Lactation
Medical & surgical conditions in pregnancy
Menopause
Modes of sexual expression
Mood Disorder
Multifetal gestation
Ovarian neoplasms
Pelvic pain
Pelvic relaxation
Postpartum care
Postpartum hemorrhage
Postpartum infection
Postterm pregnancy
|
Preconception care
Pre-eclampsia/eclampsia syndrome
Premature rupture of membranes
Preterm labor
Preventive health care & health maintenance
Puberty
Sexuality
Sexual assault/domestic violence
Sexually transmitted disease
Substance abuse
Surgical complication
Third-trimester bleeding
Thromboembolic disorder
Urinary incontinence
Urinary tract infection
Uterine leiomyoma
Vulvar or vaginal disease/disorder
Vulvar neoplasm |
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Presenting Complaint 3:
(select
one) |
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*None
Abortion
(any type)
Abnormal labor
Abnormal
uterine bleeding
Amenorrhea/Oligomenorrhea
Antepartum care
Breast disorder
Cervical disease
Cervical neoplasia
Contraception/Sterilization
Dysmenorrhea
Ectopic pregnancy
Endometrial carcinoma
Endometriosis
Fetal death
Fetal growth abnormalities
Fetal surveillance
Genetic & heredity concerns
Gestational trophoblastic neoplasia
Hirsutism and Virilization |
Hyperglycemia/Diabetes Mellitus
Immediate care of the newborn
Infertility
Isoimmunization
Intrapartum care
Issues
of Bad News
Lactation
Medical & surgical conditions in pregnancy
Menopause
Modes of sexual expression
Mood Disorder
Multifetal gestation
Ovarian neoplasms
Pelvic pain
Pelvic relaxation
Postpartum care
Postpartum hemorrhage
Postpartum infection
Postterm pregnancy
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Preconception care
Pre-eclampsia/eclampsia syndrome
Premature rupture of membranes
Preterm labor
Preventive health care & health maintenance
Puberty
Sexuality
Sexual assault/domestic violence
Sexually transmitted disease
Substance abuse
Surgical complication
Third-trimester bleeding
Thromboembolic disorder
Urinary incontinence
Urinary tract infection
Uterine leiomyoma
Vulvar or vaginal disease/disorder
Vulvar neoplasm |
| OB/GYN
Clinical Skills & OB/GYN Procedures
(Choose all that apply)
(Clinical Skills are in Bold Print. Expected Performance Levels
of Clinical Skills are in Parentheses.) |
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Amniocentesis
Amniotomy
Biophysical profile
Biopsy, cervix
Biopsy, endometrial
Biopsy, vaginal
Biopsy, vulvar
Breast exam, screening (P)
Cervical exam for dilation (O)
Circumcision, Newborn (O)
Colporrhaphy
Colposcopy
Conization of cervix (LEEP)
Delivery,
Vaginal (P)
Delivery, Cesarean
Delivery,
Forceps
Delivery of Placenta (P)
Delivery, vacuum
Dilation & Curretage (D&C)
Document in record: SOAP format (P)
Episiotomy or laceration repair
Exam, rape trauma
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Exam under anesthesia (EUA)
Excision, condyloma
Excision or marsupialization of Bartholin Cyst
Ferning, Identify (P)
Fetal heart tones, Obtain (P)
Fetal heart tracings, Interpret (P)
Fingerstick glucose determination
Fingerstick hemoglobin determination
Foley catheter, Insertion of (P)
Fundal height, Measure (P)
History, complete medical
Hysterectomy, abdominal
Hysterectomy, vaginal
Hysteroscopy, diagnostic
Hysteroscopy,
operative
Incision and drainage
Infertility
procedure
IUD insertion/removal
Laparoscopy, diagnostic
Laparoscopy,
operative
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Leopold’s Maneuver (P)
Lysis of adhesions
Non Stress Test
Pap Smear (P)
Pelvic exam (P)
Pessary insertion/removal
Pregnancy test
Prescription for medications (P)
Salpingectomy
STD testing (P)
Staple
insertion/removal (P)
Suturing (A)
Two-handed knots (P)
Ultrasound: OB 1st trimester (O)
Ultrasound: OB 2nd trimester (O)
Ultrasound: Pelvic (GYN) (O)
Ultrasound: Vaginal, gynecologic
Urogynecologic procedure
Vulvar procedure
Wet mount (P)
None
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Notes/Comments:
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