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SOGH January 2018 Newsletter 

Dayna Smith, M.D. and Jane Van Dis, M.D.
Co-editors, SOGH Newsletter 
The Society of OB/GYN Hospitalists is dedicated to improving outcomes for hospitalized women and supporting those who share this mission.
Comments or Questions about the Newsletter?  Contact us!






Dear Colleagues, 

Recently a colleague asked me, “Do you ever just feel like you’re careening from one thing to the next?” Sadly, my answer was a resounding yes. And lately it’s been more than a “feeling.” On more than one occasion, I’ve failed to keep all the balls in the air…like realizing just minutes before the school play that the tickets I’d bought were for Saturday (and it was Sunday). Or when I stumbled through a presentation before a large audience because, as it turns out, the slide show I was running was not my updated version. Needless to say, careening is an all-too-familiar feeling.

But as I write this, the New Year is just a few days away which means it’s time to reflect on the past year, contemplate what’s ahead, and perhaps even proclaim a New Year’s resolution. I’ve never been one to declare a resolution, at least not openly, for fear that someone might actually hold me to it, or worse yet, be aware of my failure to uphold it.

But this year I’ve decided to take the “go big or go home" approach and am not only committing to a New Year’s resolution, but am proclaiming it publicly. Inspired by Dr. Haramati’s sobering yet inspiring talk “Managing Stress, Building Resilience” (1) my New Year’s resolution is to practice mindfulness in 2018. For those who may not be familiar, mindfulness simply put, is focusing the mind on what is happening in the present moment. Mindfulness can be achieved using a variety of techniques (meditation, imagery, breathing techniques, etc.) but regardless of the medium, science shows us that when we practice mindfulness, stress hormones are lowered which leads to lower  blood pressure, lower heart rate, improved concentration, and reduced feelings of perceived stress, anxiety, pain and depression (1). 

The concept of mindfulness and other practices that help to reduce stress are gaining more and more attention in medicine as the issues of stress and burnout are becoming more prevalent. This is especially good news for OB/GYN hospitalists due to the high-stress, high stakes nature of our work. In the New Year, I encourage you all to be “mindful” of these issues and when that careening feeling creeps in, that you consider giving a stress-relieving practice like mindfulness a try. This is my New Year’s resolution - and you can even hold me to it.

All the best in the New Year!

Tanner Colegrove, M.D.


References and Resources:
1) SOGH Annual Clinical Meeting, September 24-27, 2017, New Orleans, LA 

1) May Clinic Healthy Lifestyle Consumer Health


Congratulations to Dr. Meredith V. Morgan!

Dr. Meredith V. Morgan receives award presented by Dr. Terry Simon. 


The Woman's Hospital of Texas, in Houston, received three awards from a survey done by Professional Research Consultants. (PRC). The Five Star Excellence Award is for scoring in the top 10% nationally. For the 2016 survey, there were 578 hospitalists that participated. One of the awards was presented in 2017 to Dr. Meredith V. Morgan, the Medical Director for Hospitalists Services. Since its inception over nine years ago, Dr. Morgan has been at the helm of the OB/GYN Hospitalist program at Woman's, a hospital that delivers well over 11,000 babies per year. Dr. Morgan is the immediate Past President of SOGH.

Congratulations Dr. Morgan!



"CODE THIS!" (Case of the Month)

The Review of Systems

The Missing Link To Achieving The Elusive “Comprehensive” History”

by Lori-Lynne A. Webb, CPC and Renée Allen, MD, MHSc., FACOG

January, 2018

Most OB Hospitalist practices have a template that covers the 12 body systems for the review of systems (ROS) and for the physical exam section within the Electronic Medical Records (EMR) system. The “Evaluation and Services Management” publication, created and revised in 2017 by the Centers for Medicare and Medicaid Services (CMS), does not state a required number of negatives per system necessary for documentation. Instead, the publication directs you to document all positive and pertinent negative responses in the ROS section of the H&P.

According to this CMS guide; “A complete ROS inquires about the system(s) directly related to the problem(s) identified in the HPI plus all additional (minimum of ten) organ systems. Individual documentation is required of those systems with positive or pertinent negative responses. For the remaining Systems, a notation indicating all other systems are negative is permissible. However, in the absence of such a notation, you must individually document at least ten systems.” 

An important issue for OB Hospitalists is, how many systems were reviewed and what level of acuity does our documentation support?

Below are the systems that make up the ROS. To achieve a “complete” or “comprehensive” ROS review, at least ten (10) of these systems need clear documentation within the medical record for that specific encounter.

Take note that there are 14 body systems listed. Thus, 10 of the 14 must be documented to qualify for a “comprehensive” ROS.

  1. ™ ™Constitutional Symptoms (for example, fever, weight loss)
  2. ™ Eyes
  3. ™ Ears, nose, mouth, throat
  4. ™ Cardiovascular
  5. ™ Respiratory
  6. ™ Gastrointestinal
  7. ™ Genitourinary
  8. ™ Musculoskeletal
  9. ™ Integumentary (skin and/or breast)
  10. Neurological
  11. Psychiatric
  12. Endocrine
  13. Hematologic/lymphatic
  14. Allergic/immunologic

The ROS is a critical component of our documentation. Given the focused nature of many of our patient encounters in a triage or OBED, we likely aren’t going to be assessing very many systems. The complexity of our encounters are often determined by our medical decision making.

Usage of statements such as “ROS negative” or “negative other than in the HPI” is unacceptable and does not support the required documentation for a ROS when documenting the history portion of the encounter. 

While it is acceptable to use verbiage in the documentation such as, “all body systems were reviewed and are negative.” If you employ this statement in your clinical documentation, make sure you are indeed performing a 10-plus system review and that the review is pertinent to the patient’s chief complaint and HPI. Querying systems that have no relevance to the HPI is not considered appropriate practice. If you are currently using statements such as “ROS negative” or “negative other than in the HPI”, such statements only cover those systems described in your HPI and are not adequate documentation of 10 systems.

CMS notes in their recommendations for documentation of the patients’ history additional useful tips on the proper Documentation of History (click here)

  • You do not need to re-record a ROS and/or a PFSH obtained during an earlier encounter if there is evidence that the physician reviewed and updated the previous information. This may occur when a physician updates his or her own record or in an institutional setting or group practice where many physicians use a common record.You may document the review and update by:
- Describing any new ROS and/or PFSH information or noting there is no change in the information
- Noting the date and location of the earlier ROS and/or PFSH
  • Ancillary staff may record the ROS and/or PFSH. Alternatively, the patient may complete the form to provide the ROS and/or PFSH. You must provide a notation supplementing or confirming the information recorded by others to document that the physician reviewed the information.

  • If the physician is unable to obtain a history from the patient or other source, the record should describe the patient's condition or the other circumstance which precludes obtaining a history.

Example of proper ROS “comprehensive” documentation with a List by Body System for a Laboring Patient

GENERAL: The patient denies any recent weight loss or gain.  She had no fevers or chills. Denies any recent illnesses.  Denies headaches
EYES: Patient denies any diplopia, vision changes
ENT: Patient denied earache, tinnitus.
CARDIOVASCULAR: Patient denies any chest pain, palpitations or flutters.
RESPIRATORY:  Patient denies any shortness of breath, coughing or wheezing.
GASTROINTESTINAL:  Patient denies any nausea, vomiting or diarrhea.  She has had no hematochezia. 
GENITOURINARY:  The patient denies any frequency, hesitancy, urgency or dysuria. The patient does admit to having contractions that she says have been coming regularly since this morning.  She does admit to vaginal bleeding that she describes as excessive.
EXTREMITIES:  The patient denies any increased swelling or edema.
PSYCHIATRIC:  Patient denies any history of anxiety or depression.
ALLERGIES: Patient denies medication allergies, but does admit to having an allergy to cats.

Example of proper ROS “comprehensive” documentation with a Statement for a Patient with Persistent UTI:

REVIEW OF SYSTEMS: 10 body systems reviewed and are negative, except the patient still reports dysuria and polyuria. The patient has a recent diagnosis of UTI and has not yet completed her antibiotic regimen with Macrobid.

Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC and ICD10 CM/PCS Ambassador/Trainer is an E&M, and Procedure based Coding, Compliance, Data Charge entry and HIPAA Privacy specialist, with over 20 years of experience. Lori-Lynne’s coding specialty is OB/GYN office & Hospitalist Services, Maternal Fetal Medicine, OB/GYN Oncology, Urology, and general surgical coding. She can be reached via e-mail  or you can also find current coding information on her blog site:

Dr. Renée Allen served co-author of this column. She is the SOGH Liaison to the ACOG Committee on Health Economics and Coding and Co-Chair of the Development Committee.  She currently works as an OB/GYN Hospitalist with Mednax/Obstetrix at Eastside Medical Center in Snellville, Georgia.

 Questions regarding this case? Contact us at [email protected] 



AIM Obstetric Hemorrhage Safety Bundle
January, 2018

by: Stacy Norton, MD

Ready, Educate, Simulate, Repeat!

As OBGYN hospitalists, we fill a unique role on the Labor and Delivery Unit. We serve as the liaison between the hospital’s healthcare staff, administration, private physicians, and the patient. It is this unique role that makes us the perfect providers to be the champion for implementation of the AIM Patient Safety Bundles at our individual institutions. AIM, or the Alliance for Innovation on Maternal Health, works at national, state, and facility levels to promote safe health care for every woman.
With this in mind, I’d like to focus this first Simulation Corner of 2018 to the AIM Obstetric Hemorrhage Safety Bundle.

Department Ready: 

  • A department that promotes a CULTURE OF SAFETY!
  • Ensure members work as a team, communicate well, have mutual respect and support, and a shared mental model. If not, perhaps an education on TeamSTEPPS or other communication tools is needed.
  • Commit your unit to a standardization of health care processes.
  • Recognition that a reduction in variation has been shown to improve outcomes and quality of care (2).
Equipment Ready:
  • Hemorrhage cart(s): supplies, check lists, and instructions for balloons and compression stiches (see addendum).
  • Immediate access to hemorrhage medications: involve pharmacy. Periodic re-evaluation of medications to reflect current guidelines and recommendation.
  • Massive Transfusion Protocol specific for OB. Involve blood bank and if applicable trauma team.
  • Establish OB Emergency Response Team: ob/gyn hospitalist, specific nursing staff, other rapid response teams, advanced gyn surgery etc.
  • Providers and nursing staff on location and contents of carts. Gnosis modules or similar programs (4).
  • Physicians on use of medicines, devices and procedures used in obstetric hemorrhage.
  • Regularly scheduled and unscheduled unit-based drills.
  • Post drill debriefs.
  • Debrief actual hemorrhages.
  • Post event debrief - identify successes and opportunities for improvement.
  • Fill in education gaps, apply process improvements as needed, specific to your facility
Repeat & Report:
  • Review serious hemorrhages and look for opportunity for improvements.
  • Monitor outcomes and keep metrics for quality improvement.


Length: 10-30 minutes depending on end point chosen by user.

Physical Space: Delivery room with possible transfer to operating room.

Primary Issue being assessed: Staff knowledge and treatment of obstetric hemorrhage. (Keep in mind user may modify drill to assess effective communication in emergencies, patient flow in a physical space, unit’s preparedness with necessary tools and materials to meet staff’s needs in an emergency etc.).


  • Ms. A.N. is a 37-year-old, G6P4 who just delivered a 4100 gm male infant. She had gestational diabetes (poorly controlled) and polyhydramnios.
  • The placenta has not yet delivered. Her blood pressure is 128/71, Pulse 102, Temp 36.7 Celsius.
  • There is a large amount of vaginal bleeding.
  • Pt is conscious and alert currently. States she is starting to feel funny.
  • Scene opens with primary Ob, labor room nurse, patient and concerned family member in the delivery room.
Additional Information:
Weight: 225 lb
PMH: Gestational diabetes
PSH: None
Meds: glyburide 5mg daily, PNV
SH: denies all toxic habits
FH all healthy per pt
Blood type  B+
CBC : WBC 11.2    H/H  11.7/33.1   Plts  165
She is typed and screened, no crossed matched blood.
  1. Primary obstetrician
  2. Delivery room nurse
  3. Concerned family member
  4. Anesthesiologist
  5. Support nurse
  6. Support physician
  7. Runner for the blood bank.
  8. Simulation observer assessing whether objectives and goals are met.
Participants should go through steps of:
  1. Administration of postpartum pitocin immediately after cord is clamped and prior to delivery of placenta.
  2. RN and MD to have a running assessment of  qualitative blood loss.
  3. Call for additional help:  additional OB, anesthesiology, charge nurse, etc.
  4. Call for hemorrhage cart.
  5. Start another IV line.
  6. Begin use of uterotonics medications, then devices or sutures.
  7. Keep patient and family informed.
  8. Debrief the event.
Goals of the simulation include:
  1. Participants promptly recognize the diagnosis of postpartum hemorrhage.
  2. Participants recognize/identify changes in patient's vital signs and symptoms.
  3. Participants use best available evidence to treat hemorrhage.
  4. Participants understand the importance of good teamwork in the management of hemorrhage.
  5. Tasks are delegated and help is sought and received.
Simulation end options. Simulation drill ends with:
a)    Bleeding responds in delivery room with use of meds.
b)    Bleeding responds in OR s/p
- D&C for retained products or
- Identification and treatment of laceration or
- Placement of compression balloon

c)    Bleeding responds in OR s/p x-lap where compression sutures are used, or hysterectomy, or no response s/p hysterectomy and patient goes into DIC.

  1. What went well?
  2. What were some obstacles?
  3. What are areas for improvement?

I hope you will join me in my "New Year's Resolution" of helping my facility implement and execute both the AIM Patient Safety Bundles of Obstetric Hemorrhage and Hypertension by the end of 2018!
Happy New Year!

References and resources:

  1. Council on Patient Safety | Women & Mothers' Health Carewebsite
  2. ACOG Practice Bulletin Summary Number 183, October 2017
  3. ACOG Committee Opinion Number 629, April 2015
  4. TeamSTEPPS
  5. Gnosis;
SOGH Simulation Co-Chair
Dr. Norton is the Team Lead physician at Memorial Herman The Woodlands Medical Center. Questions or comments, please email us at [email protected]
Sample Hemorrhage Cart
DRAWER # 1  
PPE’s (gown, hat, shoe covers) 1 set
Drapes 2
Buttocks Drapes 1
Massive Transfusion Protocol slip for Blood Bank 1
C/S Papers 1
Locks for drawers 1 pkg
Blood Transfusion Procedure 1
KY Jelly 1
O2 Mask 1
Betadine 2
Red Rubber Catheter 1
IV Start PACK 1
Lab Draw Supplies - (Vacutainer, gauze, alcohol prep, blood tubes:1 blue, 1 pink, 2 gold, 1purple, tourniquet, band- aids) 1 pkg
Injection Needle & Syringe3 (22 gauge) 3 each
Extras tray- 2 ea: 18G, 20G & Butterfly catheters, 3 vacutainer hubs, 5 vacutainer needles, 5 vacutainer adaptors  
Blood tubing & Pressure Bag 1 each
Gloves Various sizes
Sutures-1-0 Chromic CT-1, 2-0 Chromic CT-1, 2-0 Chromic SH, 2-0 Chromic V-34,3-0 Chromic CT-1, 3-0 Chromic SH,2-0 Vicryl CT-1, 2-0 Vicryl SH, 3-0 Vicryl CT-1, 3-0 Vicryl SH 3 each
16” Vaginal Swabs 4
Sterile Towels 1 pkg
Laps 2 pkg
Kerlix 1 pkg
Vaginal Packing Large & Small 1 each
4x4’s 2 pkg
RF Assure Drape 1 pkg
DRAWER # 4  
Disposable Speculum 1
Instruments: Large Curette, Rt. Angle Retractor, 1 each
Postpartum Hemorrhage Instrument Tray 1
Postpartum Hemorrhage Balloon 1
Foley 1
60 cc syringe 2
Leg Bag for Balloon drainage 1