Please read through the encounter below and create an Initial SOAP Note and post below.

Practice Charting Scenario 1

Jill has come (obviously pregnant) for an initial prenatal apt with her partner, Josh  and young daughter (appearing 4 years old).

MW: welcome, so nice to meet you, What makes you want to choose midwifery care for this pregnancy? 

Jill: I just thought it would be nice this time, last time was horrible, and so was the time before that.

MW: so tell be about your previous births?

Jill: Well Angela was long and exhausting, felt like I was in the hospital for ever, and they gave me every drug known to man and then in the end they took her from me and I was unconscious.

MW: oh gosh, that sounds really traumatic, Can I ask you a few more details?

Jill: nods

MW: first how far along we you?

Jill: like how many months?

MW: yes, exactly, do you remember how many weeks pregnant you were?

Jill: I know I was eight months pregnant when the doctor told me to come to the hospital.

MW: so you didn’t go into labor yourself?

Jill: I was having painful contractions.

MW: before or after you got to the hospital?

Jill: after

MW: so I know you were afraid and it can be hard to remember all the details, but do you remember if anyone said the words induction or pitocin?

Jill; Yeah I think they did.

MW: and do you remember why you were asked to go to the hospital?

Jill: yeah my doctor was worried about my blood pressure.

MW: do you remember the number readings that the doctor was concerned about?

Jill: 90 over 150 maybe, I really dont know.

MW: ok, well I think we can get clarity if we order your records from your old doctor. Do you have another child?

Jill: Yes, Amy, she was a long time ago.

MW: What year was she born?

Jill: she was born in 2015 

MW: do Amy and Angela are close to the same age?

Jill: yeah they would have been.

MW: Can you tell me the story?

Jill: Amy was my first pregnancy, I was young and stupid, the dad ran out on me and then she died.

MW: I’m sure you were doing the best you could. Can you tell me the circumstances of Amy’s birth and death?

Jill: Well I dont know really, she was just kicking one day and then gone the next day at my doctors appt.

MW: so do you remember how far along you were?

Jill: I was eight months pregnant.

MW: well I think again, ordering records is going to be very important, is that ok with you?

Jill: sure whatever will help me stay away from the hospital I’ll do.

MW: Josh, How are you feeling about choosing midwifery care for this pregnancy?

Josh: Um, Its fine I guess, I dont know about babies, so I guess Jill will know what to do.

MW: Is this your first baby Josh?

Jill: yeah this is our first baby together, but he has a daughter from a previous relationship.

MW: and do you get to see that daughter much?

Josh: nah, her mama moved away and I really never see her, wasn’t there when she was a baby cause I got in trouble with the police a bit.

MW: I see, well, Sounds like you two are making a fresh start, and you want to do things differently this time.  We will do what we can to help you, but to be clear, you must be low-risk to work with midwives, and we need to order your records to determine that.  Can you tell me how far along you are with this pregnancy?

Jill: Yeah I’m 6 months now and starting to get scared.

MW: So when was your last period, Jill?

Jill: I dont know, I dont seem to be regular, so I can never keep track.

MW: have you seen a doctor or midwife or had an ultrasound this pregnancy?

Jill: Yeah I was bleeding in the beginning and has an Ultrasound in the ER and then yeah saw a doctor once, but I didn’t like him

MW: So could we order those records too?

Jill: Sure as long as I dont have to go there.

MW: no we’ll do that over a fax machine if we just get a signature from you today.

Jill OK

MW: Jill have you been feeling well in this pregnancy besides the bleeding in the beginning?

Jill: Yeah, i threw up a bunch, but now I’m fine

MW: and what do you eat for breakfast usually?

Jill: well me and Angela have cereal and a banana most mornings.

Josh: and I make eggs on the weekends

MW: thats awesome, Eggs have a lot of nutrition. Jill, do you feel the baby move every day?

Jill: yes I do.

MW: where are you guys living right now?

Jill: we stay with my mom in Redmond.

MW: oh thats quite a ways away from here, there are midwives in that town, do you want me to give you a referral closer?

Jill: no, we like you - this is fine.

MW: OK, well, I have a few more questions, ok?

Jill: Sure

MW: Can you tell me why you want midwifery care specifically?  What are you hoping we can do for you that you cant get at the hospital or with doctors?

Jill: I’m not sure really, I just was following a IG influencer who was posting about her midwife and the pictures were so beautiful, I thought, I want ‘that’, so I googled midwife and your website popped up and its really beautiful.

MW: thanks, I like my website too, but I want to chat about the parts of birth that aren’t so beautiful.  When you work with my practice here, we dont offer any pain medication at all, is that something youre comfortable with?

Jill: Yes, I had medicines and they gave me so many last time I couldn’t even remember my name.

MW: yes, sometimes there can be over medication that can leave you feeling yucky, do you remember was it pain medication they gave you?

Jill no I dont know, I was just a pin cushion before and after they were always coming and taking blood and putting more things in my IV.

MW: yes, I can see how you might want to do things differently. One more question, women who birth with me, choose to birth in their own house, called a homebirth, is that what you want also?

Jill: huh, I never thought of birthing in my own house... thats kinda strange.. Couldn’t I come here to your clinic to have my baby?

MW: Jill this is an office space not suitable to birth. We would want you to have privacy and comfort and I can’t guarantee that here in this room in the chiropractor’s office.  Maybe something for you to think about is finding a doula to work with.  Have you ever heard of a doula?

Jill: thats like what you are right?

MW: nope, I’m a midwife, i provide clinical care the same as a doctor, I just dont do surgery or pain medication.  A doula is non-clinical labor support, this is someone you could work with prenatally and they go to the hospital with so you could have someone there to help you understand whats going on and help you cope with your labor and meeting your baby.  Can I give you some numbers?

Jill: sure that sounds really nice, like someone to help me figure out what to do when I’m scared.

MW: yes exactly. 

Jill: Can I still sign up to work with you too?

MW: Jill, I am happy to order your records and review them with you, however, it seems from your story that you haven’t had very much prenatal care this pregnancy, and that you have had two preterm births and one fetal demise, I’m not sure yet, but these things seem to move you out of the low-risk category and so I’m not sure you’re a good candidate for midwifery care out of the hospital.  But I want to connect you with a community doula and a pregnancy care support group so that you can have a different experience this time. Can I make those referrals for you?

Jill: Yeah that sounds good, thanks.

MW: Jill, I dont usually do a check up on someone before they are officially signed up as clients, can I help you make an appt to see the hospital midwives clinic today?

Jill: So midwives like you are at the hospital too?

MW: Midwives work in all care locations, so yes, although their offices are bigger. (Smiling).

Jill: Ok so no check up today.

MW: I thinks it’s best to have you seen by the ones who will keep seeing you ok?

Jill: OK. Thank you.