MSXX - Physician

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MSXX - Physician

OUTPATIENT FETAL MONITORING REFERRALJIM PATTISON OUTPATIENT CARE AND SURGERY CENTRE*MSXX*MSXX104471ARev: Nov 5/10Page: 1 of 1JPOCSC 9750 140th Street Surrey, B.C. V3T 0G9 Phone: (604) 582-4558 ext 763994 Fax: (604) 582-3798Patient's Full Legal Name:Other Name(s) (if applicable):Personal Health Number:Address:Home Phone No.Last First MiddleDate of Birth: / / Gender: M F(DD, MM, YYYY)Street City Province Postal CodeOkay to CallMessage Phone No.Insurance Type MSP WCB Out-of-Province Self-Pay Other: RCMP or Armed Forces #:Interpreter Required: No Yes Language:Age at referral:Age at EDC:Pre-registered at: SMH LMH PAH OtherLMP: (DD/MM/YY) Circle which is the final EDC Date of earliest ultrasound: (DD/MM/YY)EDC by LMP: EDC by U/S:Regular cycle?(DD/MM/YY) (DD/MM/YY)Gestational age at earliest ultrasoundMultiple Pregnancy: uncomplicated (>34 weeks)Reduced Placental Function: (IUGR/Oligo < 5th %)Decreased fetal movementMedical disorder (APA, lupus, cholestasis, blood dyscrasias)Additional Comments:PLEASE COMPLETE IN FULL AND PRINT CLEARLYG T P SA TA L Multiple gestation: Yes NoTwins Triplets OtherReason for Referral to Outpatient Fetal Monitoring ( Please see reverse side for criteria details)Hypertension without adverse conditions. with adverse conditions PolyhydramniousPost-dates (> 41 weeks)CholestasisAntepartum hemorrhage: Previa/recurrent abruptionSubstance useFetal anomalyMorbid Obesity BMI > 35Diabetes in Pregnancy: Type 1 & 2 (>28 weeks), Gestational requiring insulin (>34 weeks)Previous unexplained stillbirth at weeks gestationFrequency for NST:As per protocol guidelinesPrintshop # 261988THE FOLLOWING RECORDS MUST BE RECEIVED TO PROCESS THIS REFERRALAntenatal Record Part I and Part II (If started)Family Physician (if different from referring source)Name:Phone:Reports of all ultrasounds done in this pregnancyAll available lab results; including serum integrated prenatal screen results, blood group and screen, CBC,prenatal screen, PAP smear results, FBS 2 hour OGTT (where indicated), A1C (within 3 months),electrolytes (if applicable, i.e. NVP), vaginal swabsAll consultation reports and investigational records related to maternal diagnosisFax:Referring Health Care Provider:Patient has no GP/NP GP Specialist NP Hospitalist ER OtherReferring Physician Signature:Name:MSP #: MSP #:Phone:Fax:


OUTPATIENT FETAL MONITORINGREFERRAL Cont'dBack of Page 1GUIDELINES FOR THE FREQUENCY OF NON STRESSTESTING IN OUT-PATIENT FETAL MONITORINGINDICATIONFREQUENCYINITIAL GEST. AGEHypertension (dBP > 90mmhg):without adverse conditionswith adverse conditionsPre-existing hypertensionDecreased placental function: IUGR (abd. circ. < 10th %ile) Oligo (AFI 32 weeks> 26 weeks34 - 36 weeks> 26 weeksPROM stable 3 x per week When diagnosed > 26 weeksDiabetesPregestational (type 1 & 2) DiabetesGestational diabetes requiring insulinweeklyweekly> 34 weeks> 36 weeksPost dates 2 x per week > 41 weeksDecreased fetal movement 1 x only Upon recognitionMultiple Pregnancy As per specific As per specific conditionconditionUncomplicated1 x per week> 34 weeksAntepartum hemorrhage:Previa 1 x per week Upon recognitionRecurrent abruptio2 x per week> 26 weeksPrevious unexplained stillbirth 1 x per week Based on GA of previousstillbirthMedical disorder (APA, lupus,cholestasis, blood dyscrasias)1 x per week > 26 weeksPolyhydramnios 1 x per week Upon recognitionSubstance use 1 x per week > 26 weeksFetal anomaly 1 x per week > 26 weeksMorbid Obesity (BMI > 40) 1 x week > 34 weeksUpdated Feb 2011 R Kerr

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