SERVICE LEARNING INTEGRATION ACTIVITY 10:

OBSTETRICAL HISTORY AND RECORDING

NAME: CAACBAY, KATELENE A.

GROUP NO.: 4
DEPARTMENT: DEPARTMENT OF COMMUNITY AND FAMILY MEDICINE
TOPIC: OBSTETRICAL HISTORY AND RECORDING
APPROACH: ONLINE LEARNING
ONLINE PLATFORM: via Zoom Link
SPEAKERS: DR. CAROLYN TABORA Y BALLESTEROS, MD
DATE: September 10, 2022

Reflection on the Attainment of the Program

Program Outcomes
1. Demonstrate clinical competence
2. Communicate effectively
3. Lead and manage health care teams
Outcomes During the Activity
I am one of the current clerks of the LRDR in the
OB-Gyne department. Before doing anything to
our patients, we would always look into their OB
history and physical examination sheet. From
there, we would know her condition, any comorbid
and what to look out for that patient. Two days
ago, I had a patient who had chronic
hypertension. From there, I already knew what to
expect from her CTG, and I would know when to
push magnesium sulfate. For me, the history and
physical examination sheet serve as my guide as I
manage my patient.
We clerks have patients that were assigned to us.
When one of us got called out to the operating
room, we usually gave the OB sheet to our fellow
clerks to monitor our patients. After that, we
endorse to them the details and the current
management of the patient. Sometimes, there are
details that I miss out so, the clerk would check
the OB sheet for the other information that he
needs or is seeking. Sometimes, when the papers
are signed late, we put some notes at the top of
the sheet saying, "to complete other parts of the
history" or "to attach to chart." This way, we are
able to communicate to our fellow clerks what has
been done or what is to do with the patient.
The history and physical examination part teach
you to be a leader by giving you facts that lead
you to the proper diagnosis and treatment of the
patient. I, as the clerk, should make a
comprehensive history so I could lead my
workmates and my patient to better treatment.
4. Engage in research activities
5. Collaborate within interprofessional
teams
6. Utilize systems-based approach to
health care
7. Engage in continuing personal and
professional development
8. Adhere to ethical, professional, and
legal standards
9. Demonstrate nationalism,
internationalism and dedication to
service
10. Practice the principles of social All the information in the history and physical
accountability
Some of our patients have diseases that could lead to
fetal demise or infect the people handling them. When
I read the history, I'd see that she is suffering from a
comordbid, I would always look it up and try to
understand the case so when my resident on duty
comes and asks me a question, the answer will be
composed. I'd know which step I'll make to avoid
exacerbating the condition.
The information in our OB sheet was first
collected by the clerks assigned in the emergency
room. From there, we clerks from the LRDR will
receive the blotter and write it down to our OB
sheet. ER and LRDR clerks collaborating through
the OB sheet makes the admission of the patient
easy and smooth.
Like any other history and physical examination,
ours should always be systematized. Unorganized
information can lead to confusion, wreaking havoc
in the work place. In LRDR, we always have many
paperworks so we should be systematized as
much as possible or there will be missing papers,
missed orders etc.
The information listed in the history of the patient is
enough to know the diagnosis and management of the
patient. It also helps us continue studying when we
encounter rare cases or words.Our interpersonal skills
are also honed as we interview the patients.
There are parts of the OB history and physical
examination that are avoided to be talked about in
public but we clerks are supposed to be asking
the mothers about it such as sexual partners and
conditions related to her sexual history. We
learned to ask them properly without aiming to
embarass the patient and to talk about it as gentle
as possible make them assured that the data we
collected during the interview stays in the hospital.
examinations are confidential and we clerks
should practice accountability. All leaked
informations and photos are our responsibility.