I am having issues on how to audit an OB chart. If anyone can audit this note (which most of our OB notes look like) and give me some info on how to audit this. I am very new to OB auditing so not sure on guidelines.Can i use the info the providers use under the ob visit heading as HPI? 
ACTIVE PROBLEMS
- tdap vaccine
CHIEF COMPLAINT
the chief complaint is : ROB
HISTORY OF PRESENT ILLNESS
patient is a 28 yr old female. the baby can be felt moving in the uterus. taking medication,prescrption medication. not taking dietary supplements. no over the counter medication. not on herbal supplements. no pain. no preterm labor pains. and her water did not break preterm. no pruritus. no consultation with a specialist since last visist no recnt hospitalization since last visit. no previous emergency room visit since last visit.
PASTMEDICAL/SURGICAL HISTORY
reported:
environmetal exposure: no secondhand cigarette smoke exposure
SOCIAL HISTORY
Behavioral : No tobacco use.
PHYSICAL FINDINGS
- Vital taken 06/05/2013 09:12am
BP- sitting L 100/60 mmHg 100-120/56-80
BP cuff size Regular
Weight 168 lbs. 98-183
OB VISIT
return visit
risk factors
Tdap vaccine (Score: 0)
age: 28y
Gravida 2 FT: 1 Preterm : 0 Ab: 0 Liv: 1
EDD: 08/15/2013 (by LMP)
Gestational Age: 29 weeks 6 days
Weight: 168lb baseline weight: 145lb weight change: +23lb
Fetal movement (as per patient): positive
Uterine size/ fundal height: 28cm
presentation: vertex
fetal heart rate: 150 bpm
edema: none
DMS/CBC; sciatica stable-with stretching and with rest
ASSESSMENT
- supervised Other Normal Pregnancy
PLAN
supervised other normal pregnancy
lab: CBC (complete blood count)
lab:Glucose load (O'Sullivan)
-medication list reviewed and updated by provider
- no vaccines needed today
- clinical summary provided to patient
- follow up visit 2 weeks
PATIENT INSTRUCTIONS
instructions for patient; instructions for patients lanbs have been ordered. Please go to lab to have them draw as instructed by your care team.
A follow up appointment has been made.
SIGNED
ACTIVE PROBLEMS
- tdap vaccine
CHIEF COMPLAINT
the chief complaint is : ROB
HISTORY OF PRESENT ILLNESS
patient is a 28 yr old female. the baby can be felt moving in the uterus. taking medication,prescrption medication. not taking dietary supplements. no over the counter medication. not on herbal supplements. no pain. no preterm labor pains. and her water did not break preterm. no pruritus. no consultation with a specialist since last visist no recnt hospitalization since last visit. no previous emergency room visit since last visit.
PASTMEDICAL/SURGICAL HISTORY
reported:
environmetal exposure: no secondhand cigarette smoke exposure
SOCIAL HISTORY
Behavioral : No tobacco use.
PHYSICAL FINDINGS
- Vital taken 06/05/2013 09:12am
BP- sitting L 100/60 mmHg 100-120/56-80
BP cuff size Regular
Weight 168 lbs. 98-183
OB VISIT
return visit
risk factors
Tdap vaccine (Score: 0)
age: 28y
Gravida 2 FT: 1 Preterm : 0 Ab: 0 Liv: 1
EDD: 08/15/2013 (by LMP)
Gestational Age: 29 weeks 6 days
Weight: 168lb baseline weight: 145lb weight change: +23lb
Fetal movement (as per patient): positive
Uterine size/ fundal height: 28cm
presentation: vertex
fetal heart rate: 150 bpm
edema: none
DMS/CBC; sciatica stable-with stretching and with rest
ASSESSMENT
- supervised Other Normal Pregnancy
PLAN
supervised other normal pregnancy
lab: CBC (complete blood count)
lab:Glucose load (O'Sullivan)
-medication list reviewed and updated by provider
- no vaccines needed today
- clinical summary provided to patient
- follow up visit 2 weeks
PATIENT INSTRUCTIONS
instructions for patient; instructions for patients lanbs have been ordered. Please go to lab to have them draw as instructed by your care team.
A follow up appointment has been made.
SIGNED