Maternal & Public Health Programs
Maternal & public health program note template
One structure for maternal and community health contacts: the clinical record a colleague needs, plus the indicator lines a register, monthly summary or program report needs, captured in the same conversation.
Best used for
- Antenatal and postnatal contacts
- Routine immunisation sessions
- Growth monitoring and nutrition screening
- Community outreach and PMTCT visits
Template structure
Each section shows what to document and a worked clinical example.
State the contact type and number against the program schedule, gestational age with how it was determined, parity, and the interval history. Screen danger signs explicitly and record them as present or absent — headache, blurred vision, epigastric pain, bleeding, leaking liquor, reduced fetal movement, fever, convulsions.
Example
ANC contact 4 of 8, 30 weeks 2 days by early scan, G2P1+0. No headache, no blurred vision, no epigastric pain, no bleeding, no leaking of liquor. Good fetal movements. Sleeps under a treated net nightly. Iron-folate taken daily with occasional nausea.
Weight and change since last contact, blood pressure, temperature, PCV or haemoglobin, urinalysis, fundal height, lie, presentation and fetal heart rate. For child contacts record weight, length or height, MUAC and the resulting classification. Record HIV, syphilis and hepatitis B screening status with the date performed.
Example
Weight 63 kg (+1.5 kg). BP 112/70. Temp 36.8 C. PCV 33%. Urinalysis: no protein, no glucose. Fundal height 30 cm, longitudinal lie, cephalic presentation, fetal heart 142 bpm. No pedal oedema. HIV negative and syphilis non-reactive at booking; hepatitis B negative.
State whether the contact is progressing normally against the program standard, name any condition identified with its classification (mild anaemia, moderate acute malnutrition, suspected pre-eclampsia), and state the risk category that determines where the woman or child should be seen next.
Example
Normal progress of pregnancy at 30 weeks in a multigravida. No pre-eclampsia features. Mild anaemia, improving on supplementation. Low-risk pregnancy suitable for continued primary-level care.
Record commodities and doses given with site and batch where applicable, supplies dispensed with quantity, counselling delivered, referral made and its expected outcome, and the next contact date. Close with a short indicator line naming the program metrics this contact satisfied — that line is what makes register entry transcription rather than recall.
Example
IPTp-SP third dose given under observation. Td dose 3 given, left deltoid. Iron-folate 60 mg/0.4 mg daily continued, 4-week supply dispensed. Birth preparedness reviewed: facility delivery, transport, funds and blood donor identified. Danger signs counselled with return-immediately instruction. Next contact at 34 weeks. Indicators: ANC4 achieved, IPTp3 given, Td3 given, ITN in use, HIV and syphilis screening complete.
Documentation tips
- Write the indicator line at the end of every contact — it takes one sentence and saves the whole monthly summary.
- Record danger-sign screening as explicit negatives; maternal death audits turn on whether the screen happened, not on whether it was normal.
- For immunisation, always capture antigen, dose number, site and batch, so an adverse event can be traced to a vial.
- Nutrition contacts should carry the MUAC number and its classification together — the number alone does not tell the next worker what was decided.
- Note referral outcome at the following contact, not only the referral itself; an unclosed referral loop is the commonest gap in community records.
Frequently asked questions
- Which contacts does this template cover?
- Antenatal and postnatal contacts, primary-level delivery summaries, family planning counselling, routine immunisation sessions, growth monitoring and nutrition screening, PMTCT and community outreach rounds.
- What is the indicator summary for?
- It restates the program-relevant facts of the contact — contact number, doses given, screening status, classification, referral — in one place, so entering the register or the monthly summary is copying rather than recall.
- Can this be used offline during outreach?
- Yes. ScribeMDPro captures the contact and stores it encrypted on the device, then syncs when connectivity returns, so outreach without network is fully supported.
- Is any of this data sent to a ministry or donor automatically?
- No. Records belong to the clinician and their facility, and nothing leaves the account unless the facility explicitly exports it.
More templates
Let ScribeMDPro draft your maternal & public health programs notes.
Record the visit, review the draft, approve. The structure on this page is generated for you.