Unique Plan Description: MFM Preterm Labor Consult Clinic
Plan Selection Display: MFM Preterm Labor Consult Clinic
PlanType: Medical                                 
Version: 1          
Begin Effective Date: 2012-03-30 16:45:08
End Effective Date: 2100-12-31 00:00:00
Last Updated Date: 2023-04-18 10:00:42
Available at all facilities: Yes

MFM Preterm Labor Consult Clinic
Laboratory
Amniotic Fluid Testing
	UNMC Reproductive Chromosome Rflx to FISH
		T;N, Routine, spec type = Amniotic Fld
	FISH Studies with Reflex - WH/MFM/Repro
		T;N, Routine, spec type = Amniotic Fld
Cervical/Vaginal Specimens
	Culture Routine
		T;N, Routine, Micro Swab, spec type = Cervix
		T;N, Routine, Micro Swab, spec type = Vaginal
	Yeast and Trich Wet Prep - MH/WH
		T;N, Routine, spec type = Genital
	Wet Prep - PC/FH
		T;N, Routine, spec type = Genital
	Fetal Fibronectin
		T;N, Routine, spec type = Swab
	Group B Strep by PCR
		T;N, Routine, spec type = Vaginal/Rectal
	GC/Chlamydia PCR-MH/WH/PC
		T;N, Routine, spec type = Cervix
		T;N, Routine, spec type = Vaginal
	Urine GC/Chlamydia PCR - MH/WH/PC
		T;N, Routine, spec type = Urine
	GC/Chlamydia(Rapid) DNA - FH/JE
		T;N, Routine, spec type = Cervix
		T;N, Routine, spec type = Urine
		T;N, Routine, spec type = Vaginal
		T;N, Routine, spec type = Urine
Urine Studies
	UA (Culture if Positive)
		T;N, Routine, Routine, Urine, spec type = Urine
	Protein Urine Timed Set
		T;N, Routine, Routine, Urine, spec type = Urine
	Creatinine Urine Timed Set
		T;N, Routine, Routine, Urine, spec type = Urine
Medications

	betamethasone acet-betamethasone na phosphate (Celestone Soluspan) (In Office)
		12 mg, Injection, IM-Intramuscular, Once, NOW
	RHo (D) immune globulin 300 mcg (In Office)
		1,500 intl_units, Solution, IM-Intramuscular, Once, NOW
Consults/Follow-up
	Follow-up Appointment
		Follow Up Visit, 2 weeks
		Follow Up Visit, 1 month
		Follow Up Visit, 3 months
		Follow Up Visit, 6 months
		Follow Up Visit, 1 week
		Follow Up Visit, 3 weeks
		Follow Up Visit, 6 weeks
		Follow Up Visit, PRN
		Follow Up Visit, See Special Instructions
		Follow Up Visit, Today
	Request for Service
		
	Surgery to Schedule
		
	Consult Other
		
Charges/Supplies
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
New Pt Visit
	zz99201 EVM-New Pt Visit Problem focused 10m
		T;N
	99202 EVM - OP VISIT NEW PATIENT, STRAIGHTFORWARD 15 MIN
		T;N
	99203 EVM - OP VISIT NEW PATIENT, LOW LEVEL 30 MIN
		T;N
	99204 EVM - OP VISIT NEW PATIENT, MODERATE LEVEL 45 MIN
		T;N
	99205 EVM - OP VISIT NEW PATIENT, HIGH LEVEL 60 MIN
		T;N
Procedures in Office
	59000 CP Amniocentesis, diagnostic MFM
		Additional Fetus 0
		Additional Fetus 1
		Additional Fetus 3
	Fetal Non-Stress Test
		
	Level 1 U/S (in office)
		Additional Fetus 0
		Additional Fetus 1
		Additional Fetus 2
		Additional Fetus 3
	76811 Level II U/S  -MFM
		Additional Fetus 0
		Additional Fetus 1
		Additional Fetus 2
		Additional Fetus 3
	76816 US OB Follow-up (in office)
		Cervical Length, Additional Fetus 0
		Cervical Length, Additional Fetus 1
		Cervical Length, Additional Fetus 2
		Cervical Length, Additional Fetus 3
	76815 US OB Limited (in office)
		Cervical Length, Additional Fetus 0
		Cervical Length, Additional Fetus 1
		Cervical Length, Additional Fetus 2
		Cervical Length, Additional Fetus 3
	76818 US Fetal Biophysical Profile (in office)
		Other, Additional Fetus 0, Cervical Length
		Other, Additional Fetus 1, Cervical Length
		Other, Additional Fetus 2, Cervical Length
		Other, Additional Fetus 3, Cervical Length
	76819 US Fetal Biophys w/o Stress (in office)
		Other, Additional Fetus 0, Cervical Length
		Other, Additional Fetus 1, Cervical Length
		Other, Additional Fetus 2, Cervical Length
		Other, Additional Fetus 3, Cervical Length
	76817 US OB Transvaginal (in office)
		Cervical Length, Additional Fetus 0
		Cervical Length, Additional Fetus 1
		Cervical Length, Additional Fetus 2
		Cervical Length, Additional Fetus 3
	76827 Doppler (in office)
		Additional Fetus 0
		Additional Fetus 1
		Additional Fetus 2
		Additional Fetus 3
	76828 Doppler F/U (in office)
		Additional Fetus 0
		Additional Fetus 1
		Additional Fetus 2
		Additional Fetus 3
	93770 Ductus Venosus (in office)
		Additional Fetus 0
		Additional Fetus 1
		Additional Fetus 2
		Additional Fetus 3
	76825 Doppler Echo, Fetal, 2D (in office)
		Additional Fetus 0
		Additional Fetus 1
		Additional Fetus 2
		Additional Fetus 3
	76826 Doppler Echo, Fetal F/U (in office)
		Additional Fetus 0
		Additional Fetus 1
		Additional Fetus 2
		Additional Fetus 3
	76820 Doppler Umb Artery (in office)
		Additional Fetus 0
		Additional Fetus 1
		Additional Fetus 2
		Additional Fetus 3
	76821 Doppler Mid-Cerebral Artery (in office)
		Additional Fetus 0
		Additional Fetus 1
		Additional Fetus 2
		Additional Fetus 3
	76820 Doppler Umb Artery (in office)
		Additional Fetus 0
		Additional Fetus 1
		Additional Fetus 2
		Additional Fetus 3

Creatinine Clearance Set
Laboratory

	.Urine Time and Volume
		T;N, Routine, Routine, spec type = Urine
	.Creatinine
		
	.Cclr

*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