li1 - Philippine Health Insurance Corporation
li1 - Philippine Health Insurance Corporation
li1 - Philippine Health Insurance Corporation
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tioi<br />
lea<br />
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@red<br />
onDischarge<br />
ipropnaccboxfoi<br />
pauenrwnsdischn<br />
HomeAgainstM<br />
(KAMA),AbscondedorExpired<br />
diedisposition<br />
rgedImproved,<br />
-dicalAdvice<br />
gEpilepsy<br />
hRenaldisease<br />
iBleedingdisorders<br />
1Historyofpreviouscaesanansection<br />
kHistoryofuterinemyomectomv<br />
Part II Maternity Cart Package (MCP)<br />
CF3 Part II shall be accomplished for MCP claims and<br />
must be submitted together with CF1 and CF2.<br />
5<br />
AdmittingDiagnosis<br />
Writetheadmittingdiagnosisofdiepatient<br />
Item<br />
No.<br />
Description/ Procedure<br />
PRENATAL<br />
Initial Prenatal Consultation<br />
Wine the- date of the initial prenatal consultation of<br />
tilt patient following die prescribed format fot dace.<br />
Clinical History and Physical Examination<br />
Vita) si^tis ate normal<br />
Check die box provided if die vital signs of the<br />
patient '.ire normal.<br />
(ib<br />
Writetheexpecteddaleofdeliveryfollowingthe<br />
prescribediormatfordate.<br />
Ascertain the present pregnancy is low risk-<br />
Check die box provided if present pregnancy is low<br />
nsk<br />
Menstrual History<br />
Indicate die dale of Last Menstrual Peiiod (LMP)<br />
following die prescribed format toi date and Age of<br />
Menarche.<br />
Obstetric History<br />
Write the Obstetric Seme of die patient by indicating<br />
die number of pregir.tncy./pregnancies (G) and the<br />
number of piegnancy/pregnancies Unit reached<br />
vi.ibilin' (P) The next four (4) blanks correspond to<br />
pregnancy outcome (Terr/i, Pralerm. .Abortion and<br />
Uvmg)<br />
lUitsirdtiQii A mother on hei duid pregnancy has had<br />
2 deliveries to m-o (2) Live, term offspring widi no<br />
hisiory of nboiiion.<br />
The obstetric score shall be<br />
7c<br />
7d<br />
Writedieweightandvitalsignssuchaycardi-aclate,<br />
respnaiorvrate,bloodpressureandtemperature<br />
conespondingtotheconsultation.<br />
DELIVERYOUTCOME<br />
Obstetric Risk Factors<br />
8<br />
WntediedateandtimeotdeliverytoUowmgdie<br />
ptesciibedformatfoidateandlime.<br />
Check die appropriate box it patient has any of the<br />
following obstetric risk factors:<br />
a.Multiple pmgn.incy<br />
b.Ovauiiui cyst<br />
c Myoma uixn<br />
d. Placenta pic via<br />
e Histoiy of 3 rmscamages<br />
1". Histoiy oi stiHbirLJi<br />
g. Mistoiy of pre-eclampsm<br />
h Histoiy of eclampsia<br />
1 Premature contraction<br />
9<br />
Wnlediematernaloutcomeasto.<br />
@ObstetricIndex-IndicatetheObstetricIndex<br />
eg.,G3P3(3003)<br />
@AOGbyLMP-IndicatetheAgeofGestation<br />
(AOG)mweeksbasedondieLastMenstrual<br />
Peiiod(LMP).<br />
@MannerofDelivery@Indicatediemannerof<br />
dekvery(NSD,assisted)<br />
@Presentation-Indicatethepresentationofdie<br />
fetus(cephalic,lueech,compound)<br />
Medical/ Surgical Risk Factors<br />
Check the appropriate box if p:iUcj.K has<br />
following mtdicdt/sui-giciil us!: faciors.<br />
a.Hypertension<br />
b.Heine Disease<br />
c.Diabetes<br />
d.Thyroid disorder<br />
e Obesitjf<br />
Moderate- to Severe Asthma<br />
of die<br />
10<br />
BirthOutcome<br />
WntethebhthoutcomeoitheIcaisasto<br />
@FetalOutcome@Indicatewhetlieithefetus<br />
isalive("live")ornotsuchas"fetaldeath"or<br />
"sullbudi".<br />
@Sex@Indicateihcsexoithefetuswnctlier<br />
femaleormale<br />
@Birthweight-Indicatethebirdiweightof<br />
feiuiingrams
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