Unique Plan Description: MFM Postpartum Clinic
Plan Selection Display: MFM Postpartum Clinic
PlanType: Medical                                 
Version: 1          
Begin Effective Date: 2012-03-30 15:57:03
End Effective Date: 2100-12-31 00:00:00
Last Updated Date: 2021-12-06 09:50:05
Available at all facilities: Yes

MFM Postpartum/Postop 0-2 weeks
Laboratory
	CBC with Diff
		T;N, Routine, spec type = Blood
Consults/Follow-up
	Follow-up Appointment
		Follow Up Visit, 1 month
		Follow Up Visit, 2 months
		Follow Up Visit, 1 week
		Follow Up Visit, 2 weeks
		Follow Up Visit, 3 weeks
		Follow Up Visit, 3 months
		Follow Up Visit, 6 months
		Follow Up Visit, 1 year
		Follow Up Visit, See Special Instructions
		Follow Up Visit, PRN
	Request for Service
		
	Surgery to Schedule
		
Charges/Supplies
	99211n EVM - No Charge Professional Service
		
Est. Pt Visit
	99211 EVM - OP visit estab patient, minimal care < 10 min
		T;N
	99212 EVM - OP VISIT ESTAB PATIENT, STRAIGHTFORWARD 10 MIN
		T;N
	99213 EVM - OP VISIT ESTAB PATIENT, LOW LEVEL 20 MIN
		T;N
	99214 EVM - OP VISIT ESTAB PATIENT, MODERATE 30 MIN
		T;N
	99215 EVM - OP VISIT ESTAB PATIENT, HIGH LEVEL 40 MIN
		T;N

MFM Postpartum 6 weeks
Laboratory

	CBC with Diff
		T;N, Routine, spec type = Blood
	Glucose Tolerance Testing Panel (0hr, 2hr)
		T;N, Routine, spec type = Blood
	TSH
		T;N, Routine, spec type = Blood
	Free T4
		T;N, Routine, spec type = Blood
Cervical/Vaginal Specimens
	GYN Request (PAP)
		T;N, Routine TL PAP CERVICAL, Routine
		T;N, Routine TL PAP CV & VAG, Routine
		T;N, Routine TL PAP VAGINAL, Routine
		T;N, Routine PAP CERVICAL, Routine
		T;N, Routine PAP CERV & VAG, Routine
		T;N, Routine PAP VAGINAL, Routine
	GYN Pap with HPV High Risk Co-Test
		T;N, Routine TL PAP CERVICAL, Routine
		T;N, Routine TL PAP CV & VAG, Routine
		T;N, Routine TL PAP VAGINAL, Routine
	GYN Pap with Reflex to HPV High Risk
		T;N, Routine TL PAP CERVICAL, Routine
		T;N, Routine TL PAP CV & VAG, Routine
		T;N, Routine TL PAP VAGINAL, Routine
	HPV High Risk with 16 and 18 Genotyping
		T;N, Routine, spec type = Cervix
		T;N, Routine, spec type = Vaginal
Future
	Glucose Tolerance Testing Panel (0hr, 2hr)
		T;N, Routine, spec type = Blood
Medications

	medroxyPROGESTERone (Depo-Provera) (In Office)
		150 mg, Injection, IM-Intramuscular, Once, NOW
	ethinyl estradiol-norgestimate (0.035 mg-0.18 mg)-(0.035 mg-0.215 mg)-(0.035 mg-0.25 mg) oral tablet
		1 TAB BY MOUTH DAILY, # 28 TAB, 11 Refill(s)
	Altavera oral tablet
		1 TAB, BY MOUTH, DAILY, # 28 TAB, 11 Refill(s)
	Yaz 3 mg-0.02 mg oral tablet
		1 TAB BY MOUTH DAILY, # 28 TAB, 11 Refill(s)
	norethindrone 0.35 mg oral tablet
		1 TAB BY MOUTH DAILY, # 28 TAB, 11 Refill(s)
	NuvaRing 0.015 mg-0.120 mg vaginal ring
		1 EA VAGINAL Q4WK, # 1 EA, 11 Refill(s)
Consults/Follow-up
	Follow-up Appointment
		1 year
	Request for Service
		
	Surgery to Schedule
		
Charges/Supplies
	99211n EVM - No Charge Professional Service
		
Est. Pt Visit
	99211 EVM - OP visit estab patient, minimal care < 10 min
		T;N
	99212 EVM - OP VISIT ESTAB PATIENT, STRAIGHTFORWARD 10 MIN
		T;N
	99213 EVM - OP VISIT ESTAB PATIENT, LOW LEVEL 20 MIN
		T;N
	99214 EVM - OP VISIT ESTAB PATIENT, MODERATE 30 MIN
		T;N
	99215 EVM - OP VISIT ESTAB PATIENT, HIGH LEVEL 40 MIN
		T;N

PIH Panel
Laboratory
Urine Studies
	Creatinine Clearance
		T;N, Routine, Routine, Urine Timed, spec type = Urine
	C. Clearance Serum
		T;N, Routine, spec type = Blood
	Protein Urine Timed Set
		T;N, Routine, Routine, spec type = Urine
	Protein Creatinine Ratio Urine
		T;N, Routine, Routine, Urine Random, spec type = Urine
General Labs
	CBC with Diff
		T;N, Routine, spec type = Blood
	Comprehensive Metabolic Panel
		T;N, Routine, spec type = Blood

*Report Legend:
DEF - This order sentence is the default for the selected order
GOAL - This component is a goal
IND - This component is an indicator
INT - This component is an intervention
IVS - This component is an IV Set
NOTE - This component is a note
Rx - This component is a prescription
SUB - This component is a sub phase