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Progress Note and Discharge Note Examples OB LABOR NOTE
S: Comfortable with epidural” or “Breathing through contractions.” O:
1. Vitals. 2. Most recent SVE (sterile vaginal exam) performed by (RN, MD, resident) 3. Fetal tracing: baseline 140, moderate variability, accelerations, no decelerations 4. Tocometer : contractions every 4 min
A/P: SIUP at 39w1d, active labor, undergoing Pitocin augmentation, GBS +
1. Continue augmentation (or induction) with Pitocin (or cytotec, cervidil, etc) 2. Fetal tracing reassuring 3. Anticipate vaginal delivery 4. Continue GBS antibiotic prophylaxis
POSTPARTUM NOTE—VAGINAL DELIVERY
S: Normal lochia. Voiding without difficulty. Working with lactation consultant on latch. Colostrum coming in well. Minimal discomfort from vaginal laceration O: Vitals Gen Heart Lungs Fundus firm, nontender, 2 cm below umbilicus LE: 1+ edema, no calf tenderness to palpation, negative Homan sign Labs: Recent CBC A/P: G1P1 Postpartum Day #1 from spontaneous delivery complicated by shoulder dystocia, now with postpartum anemia
1. Routine postpartum care. 2. Lactation consultation ordered. 3. Iron supplementation. 4. Anticipate discharge home tomorrow.
POSTPARTUM NOTE—CESAREAN DELIVERY
S: Minimal lochia. Foley still in place. Bottle feeding. Pain well controlled with oral pain meds and Toradol. No flatus yet. Tolerating clear liquids. O: Vitals Gen Heart Lungs Abdomen (bowel sounds, guarding or rebound, distension) Fundus firm 2 cm below the umbilicus, mildly tender consistent with POD #1 Bandage clean and dry OR Incision intact (with staples or steristrips), no erythema, ecchymosis or active drainage LE exam Labs: Post op CBC A/P: G3P2 POD #1 from low transverse cesarean delivery
1. Routine postop care. 2. Lactation consultation ordered. 3. Foley out today. 4. Switch to oral pain meds. 5. Milk of magnesia to move bowels. 6. Anticipate discharge home tomorrow.
POST OP GYN SURGERY NOTE
S: Pain well controlled on morphine PCA. No nausea. Tolerating regular diet. Passing flatus. Voiding well after foley removed. O: Vitals Gen Heart Lungs Abdomen (bowel sounds, guarding or rebound, distension) Bandage clean and dry OR Incision intact (with staples or steristrips), no erythema, ecchymosis or active drainage LE exam Labs: Pathology: A/P: 58 yo G4P4 POD #3 from total laparoscopic hysterectomy and BSO, doing well.
1. Routine postop care. 2. Prescriptions written and wound care instructions reviewed. 3. Hormone replacement after ovarian removal: none needed 4. Anticipate discharge home today.
1. Home 2. Diet: ADA (American Diabetic Associate) diet if diabetic 3. Activity: stairs, showers, baths, intercourse, douches, tampons walking, high-
4. Follow-up appointment(s): Mother and Baby 5. Medications: Pain, Antibiotic, Hormones 6. Wound care: Staples, Drains, Suture removal, OK to get wet or take soaking
7. Call immediately if: fever, chills, vomiting, vaginal bleeding over 2 soaked pads
Deutscher Naturheilbund eV – Reihe „Naturheilkundliche Ratgeber“ Stärkster Grippeschutz kommt aus der NaturPflanzliches Präparat aus der ZistroseHorst Boss, Heilpraktiker und Medizinjournalist Dass gerade ein rein pflanzliches Präparat, je nach Virus- art, bis zu hundertmal stärker vor Grippeviren schützt als der Neuraminidasehemmer Oseltamivir (Tamiflu®), ist vielen M
rEViEW artiClE Postpartum Haemorrhage in the Developing World A Review of Clinical Management Strategies ABSTRACT: The developing world is disproportionately burdened with high rates of maternal mortality. Despite widespread reduction in maternal deaths due to improved antepartum, intrapartum, and postpartum care in developed nations, mortality rates are persistently high in many