Obstetrics & Gynaecology
Antenatal visit note template
A routine antenatal review structured around gestational age, maternal observations, fetal assessment and the screening schedule for that visit.
Best used for
- Routine antenatal reviews
- Midwife-led clinics
- Postnatal checks
- High-risk pregnancy follow-up
Template structure
Each section shows what to document and a worked clinical example.
Gravidity and parity, gestational age with dating method, relevant obstetric and medical history, and interval symptoms.
Example
G2 P1, 28 weeks by early ultrasound. Previous uncomplicated vaginal delivery. Reports good fetal movements, no bleeding, no leaking fluid, no headache or visual change.
Blood pressure, urinalysis, weight, fundal height in centimetres, presentation where applicable, and fetal heart rate.
Example
BP 112/70, urinalysis no protein. Fundal height 28 cm, consistent with dates. Cephalic presentation. Fetal heart rate 142 bpm by Doppler.
State which screening is due at this gestation, what was performed today, and any outstanding results being chased.
Example
Glucose tolerance test performed today, result pending. Anti-D not indicated, rhesus positive. Full blood count normal at booking.
Supplements, vaccinations, birth-plan discussion, next appointment, and the specific symptoms that should prompt immediate presentation.
Example
Continue iron and folic acid. Pertussis vaccination given. Advised to attend immediately for reduced fetal movements, vaginal bleeding, severe headache, visual disturbance or abdominal pain. Review in two weeks with glucose result.
Documentation tips
- Always record gestational age and the dating method — every clinical decision depends on it.
- Document fetal movement enquiry at every visit from 24 weeks.
- List the red-flag symptoms you actually gave; generic 'advice given' offers no protection.
Frequently asked questions
- What is recorded at every routine antenatal visit?
- Gestational age, blood pressure, urinalysis, fundal height, fetal heart rate, fetal movements, and the red-flag advice given.
- When does fundal height measurement begin?
- Commonly from around 24 weeks, plotted serially so that growth can be tracked against the expected curve.
- Can ambient documentation be used in antenatal clinics?
- Yes. Measurements spoken aloud during the examination are captured, and the clinician confirms every value during review.
- Does this template cover postnatal checks?
- The structure adapts well, replacing fetal assessment with maternal recovery, mood screening, feeding and contraception.
More templates
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