Prenatal visit note template with examples

How to write a prenatal visit note, step by step

1. Date the pregnancy first: gestational age today, how it was established (LMP or dating ultrasound), and the EDD, on every note.
2. Take the interval history since the last visit: symptoms, bleeding or leaking, contractions, fetal movement where applicable, illnesses, medications, and the patient's own concerns.
3. Measure and record today's values only: blood pressure, weight and change, fundal height, and fetal heart rate with how it was obtained.
4. Review every outstanding result since the last visit — labs, ultrasounds, screening — and document that you reviewed them, not just that they exist.
5. Assess against gestation: is growth, blood pressure, and symptom pattern what this stage predicts, and which named issues are active?
6. Order what this stage requires: glucose screening, repeat bloodwork, ultrasounds, and group B streptococcus testing at the right weeks, and immunizations per provincial guidance.
7. Document the education actually given for this stage — warning signs, birth planning, feeding intentions — in terms specific enough to be audited.
8. Close with the next appointment interval, what results are pending and who acts on them, and how the patient reaches care between visits.

Blank prenatal visit template

Gestational age today (by LMP / dating ultrasound):  |  EDD:
Gravida / para / aborta / living:

S: Subjective
Interval symptoms (nausea, pain, bleeding, discharge, contractions):
Fetal movement (if applicable):
Concerns or questions today:
Relevant interval history (illnesses, medications, exposures):

O: Objective
Blood pressure / weight (and change) / urine dip if done:
Fundal height:
Fetal heart rate and how obtained:
Edema / reflexes if indicated:
Lab results and imaging reviewed since last visit:

A: Assessment
Pregnancy status and progress at this gestation:
Active issues (e.g. GDM, hypertension, anemia) and their status:
Risk factors arising or resolved:

P: Plan
Investigations ordered (labs, ultrasound, glucose screening, GBS as stage-appropriate):
Immunizations offered/given (influenza, Tdap, RSV as per provincial guidance):
Medications or supplements reviewed (folic acid, iron, others):
Education provided for this stage (birth planning, feeding, warning signs):
Warning signs reviewed (bleeding, reduced fetal movement, headache/visual changes, contractions):
Next appointment interval and who to contact between visits:

Example: 28-week visit with glucose screening due

Gestational age 28+2 by first-trimester dating ultrasound. EDD as documented. G2P1, one prior term vaginal birth.

S: Feeling well. Fetal movement daily and strong. No bleeding, leaking, or regular contractions. Mild heartburn in the evenings. Asks about the glucose test and whether she can work until 36 weeks (desk job).

O: BP 112/70. Weight up 1.1 kg since 24 weeks. Fundal height 28 cm. Fetal heart rate 142 by Doppler. No edema. Reviewed: anatomy ultrasound at 20 weeks normal; no labs outstanding.

A: Uncomplicated pregnancy at 28 weeks, growth clinically appropriate. Heartburn consistent with reflux of pregnancy. No hypertensive or infective features today.

P: 50 g glucose challenge test ordered today with CBC and ferritin; Rh status already confirmed positive, no WinRho indicated. Tdap offered and given today; influenza vaccine already received. Iron-rich diet discussed; no supplement started pending ferritin. Education: third-trimester warning signs reviewed (reduced fetal movement, bleeding, severe headache or visual change, regular contractions before 37 weeks) and she repeats back to call the maternity unit, not wait for the next visit. Work note not required; revisit at 34 weeks. Next visit in 2 weeks, sooner for results if glucose screening is abnormal.

Who uses a prenatal visit note, and when

Family physicians, obstetricians, midwives, and nurse practitioners write prenatal visit notes at every routine antenatal contact, from booking to the postpartum handover.

• Booking and first-trimester visits with dating and screening offers.
• Routine second-trimester surveillance and anomaly-scan follow-up.
• Third-trimester growth, GBS, and birth-planning visits.
• High-risk shared-care visits (hypertension, diabetes, twins).
• Post-dates and induction-planning assessments.

Documentation, privacy, and record-keeping in Canada

Prenatal notes are longitudinal: each visit's fundal height, blood pressure, fetal heart, and screening status build the record that labour and delivery teams act on. In Canada, antenatal records (such as Ontario's Antenatal Record) standardize what must be captured, and offers of screening — and informed declination — must be documented explicitly. Results reviewed, counselling given, and the plan for the next interval belong in every note, because continuity is the safety mechanism.

Across Canada, clinical notes form part of the legal medical record. Provincial regulators expect entries that are contemporaneous, factual, and attributable; health information is handled under provincial privacy law (such as PHIPA in Ontario, the HIA in Alberta, and Law 25 in Quebec) and PIPEDA where it applies. Disclose the minimum necessary, with patient consent, and record amendments as amendments — never by overwriting the original entry.

Common mistakes that weaken a prenatal visit note

• Fundal height or fetal heart recorded with no blood pressure or urine results.
• Screening offered but acceptance or declination not documented.
• Results filed with no note that they were reviewed or acted on.
• No gestational-age-anchored plan ('return 4 weeks') as term approaches.
• Symptoms asked generically with no preeclampsia or preterm-labour review.
• Birth preferences discussed but never written where the delivery team can find them.

What makes prenatal notes fail audits

• No gestational age on the note. Every finding in obstetrics is interpreted against gestation; a note without it cannot be audited.
• Fundal height and fetal heart recorded without how they were obtained, or carried forward from last visit.
• Screening silently absent: if the glucose test, GBS swab, or a vaccine was due and not done, the note should say offered, ordered, or declined.
• Warning signs 'discussed' with no stage-appropriate content. Reduced fetal movement advice at 28 weeks is not the same talk as at 12 weeks.
• Education invisible. Birth planning, feeding intentions, and safe-sleep teaching are care, and if they are not in the note they did not happen.

What is due when: a stage checklist for the plan section

Exact timing follows SOGC guidance and your provincial prenatal programme; the documentation habit that survives audit is the same at every stage: name what was due, and whether it was done, ordered, or declined.

Example 2: 36-week visit, group B streptococcus and birth planning

Gestational age 36+1 by dating ultrasound. G1P0.

S: Feeling well, fetal movement strong and daily. No bleeding, leaking, or regular contractions; occasional Braxton Hicks in the evening. Some ankle swelling by end of day, resolves overnight. Asks about epidural and whether her partner can stay overnight after delivery.

O: BP 118/76. Weight up 0.6 kg in 2 weeks. Fundal height 36 cm. Fetal heart rate 138 by Doppler. Presentation cephalic by Leopold manoeuvres, consistent with last week's ultrasound. Mild ankle edema, reflexes normal. Reviewed: glucose challenge normal at 27 weeks, Tdap given, anatomy scan normal.

A: Uncomplicated primigravid pregnancy at 36 weeks, cephalic presentation, growth clinically appropriate. Physiologic edema only; no hypertensive features.

P: Group B streptococcus swab taken today; result will be documented in the hospital prenatal record copy she carries, and she knows a positive result means antibiotics in labour, not treatment now. Birth preferences discussed: epidural available, partner presence per current unit policy, written summary given. Warning signs reviewed with emphasis on reduced fetal movement, headache or visual changes, bleeding, or regular contractions; she will present to the maternity unit directly, day or night. Visits now weekly. Next appointment in 7 days; group B result will be called to her if positive before then.

Frequently asked questions

References

1. Good practices in medical record keeping — Canadian Medical Protective Association (CMPA)
2. Medical Records Documentation — practice standard — College of Physicians and Surgeons of Ontario (CPSO)
3. Personal Health Information Protection Act (PHIPA) — Government of Ontario
4. Clinical practice guidelines — Society of Obstetricians and Gynaecologists of Canada (SOGC)
5. A Guide to a Healthy Pregnancy — Public Health Agency of Canada

Examples on this page are fictional and for illustration only; they do not describe real patients. Templates reflect the corresponding built-in template in Scribeberry at the date above.