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Sarah Johnson, a 32-year-old female, is currently pregnant at 24 weeks gestation (G2P1) with an uncomplicated pregnancy. She has a history of gestational diabetes in a previous pregnancy. On June 1, 2024, her glucose tolerance test was normal, her blood type was confirmed as O positive, and she was found to be immune to rubella. She is currently taking prenatal vitamins with folic acid 800mcg daily and iron supplement 27mg daily. She has a booked appointment for an anatomy scan (obstetric ultrasound).

Sarah Johnson is a 32-year-old woman, gravida 2, para 1, at 24 weeks’ gestation with a confirmed, active, uncomplicated pregnancy. She has a confirmed history of gestational diabetes mellitus that developed during her previous pregnancy and is now resolved. Her glucose tolerance test in the current pregnancy is normal; numerical results and the testing protocol were not provided. Her blood type is O positive, and she is immune to rubella.

She is currently taking prenatal vitamins once daily, providing 800 micrograms of folic acid daily, and an iron supplement at 27 mg once daily.

An active order is in place for an obstetric ultrasound to assess fetal anatomy during the current pregnancy. The fetal anatomy ultrasound appointment is booked, but the appointment date, start and end times, and her acceptance status were not provided.

Sarah Johnson is a female born in 1993 (approximately 32 years old). She has a confirmed, active, uncomplicated pregnancy, currently at 24 weeks gestation, which is on her problem list. She is gravida 2, para 1 (G2P1). These findings are supported by recorded observations of gravida 2, para 1, and a gestational age of 24 weeks.

Her obstetric history includes gestational diabetes mellitus during her previous pregnancy. This condition is confirmed and now resolved. Her current glucose tolerance test is normal.

Prenatal laboratory results show blood group O Rh(D) positive. Rubella virus IgG antibody is positive, indicating she is immune to rubella.

She is currently taking two supplements for her pregnancy:

• A prenatal multivitamin containing folic acid 800 mcg, once daily
• An iron supplement 27 mg, once daily

There is an active order for an obstetric imaging study, specifically a fetal anatomy ultrasound scan, to evaluate her pregnancy. A corresponding appointment for this scan has been proposed, but no date has been specified yet. Ms. Johnson is listed as a required participant and has accepted the appointment.

Sarah Johnson is a 32-year-old female with a current uncomplicated pregnancy at 24 weeks gestation. She is gravida 2, para 1 (G2P1). Her blood type is O positive and she is immune to rubella. She has a history of gestational diabetes during her previous pregnancy, which has since resolved; her current glucose tolerance test is normal. She is taking prenatal vitamins with folic acid 800 mcg daily and an iron supplement 27 mg daily. An obstetric ultrasound for fetal anatomy scan has been ordered and is scheduled.

Clinical Narrative

Sarah Johnson is a 34-year-old female (born 1991), gravida 2, para 1, with a confirmed, active pregnancy at 24 weeks' gestation. The current pregnancy is documented as uncomplicated. She had gestational diabetes in a previous pregnancy, which is confirmed and now listed as resolved. A glucose tolerance test in the current pregnancy was normal.

Her prenatal laboratory results show blood group O positive. Her rubella antibody test was positive, indicating rubella immunity. All observations are in final status.

She has two active medication orders. The first is prenatal vitamins with folic acid, providing 800 mcg of folic acid once daily. The second is ferrous sulfate 80 mg oral tablets, with instructions to take 27 mg of elemental iron once daily.

An active order is in place for a fetal ultrasound. The next ultrasound is planned as an anatomy scan, but the record does not include a date or time for this appointment.

Documentation Note

The RxNorm code on the prenatal vitamin order (310965) appears to correspond to a different product in RxNorm, likely ibuprofen 200 mg oral tablet, rather than prenatal vitamins. Because NSAIDs are generally avoided at this stage of pregnancy, the coded medication should be verified.

The ferrous sulfate order also needs clarification. It lists an 80 mg tablet strength, but the dosing instruction specifies 27 mg of elemental iron and does not state how many tablets to take per dose.

Sarah Johnson, a woman born in 1993, is gravida 2, para 1 (G2P1) at 24 weeks’ gestation. Her active, confirmed problem-list diagnosis is an uncomplicated intrauterine pregnancy under supervision in the second trimester. Final observations document her pregnancy status, gestational age, and obstetric history. She has a confirmed history of gestational diabetes during her previous pregnancy, now documented as resolved. Glucose tolerance testing for the current pregnancy is finalized and normal. Other finalized prenatal laboratory findings show blood type O Rh(D) positive and rubella immunity based on serum rubella IgG testing.

Her active pregnancy-related medications are a prenatal multivitamin containing 800 mcg of folic acid per tablet, taken orally once daily, and an iron supplement, 27 mg orally once daily.

An active order is in place for a fetal anatomy ultrasound. The requested examination is a real-time transabdominal obstetric ultrasound with image documentation and fetal and maternal evaluation after the first trimester, for a single or first gestation (CPT 76805). The associated appointment is recorded as proposed, although the scheduling comment states that the anatomy scan is scheduled. No specific appointment date or time is provided. Sarah is listed as a required participant and has accepted participation.