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Post Partum Post Op Note

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					Magnesium Sulfate Check Note                                      L & D Progress Note
                                                                  S: Pt comfort level
S:                                                                O: Maternal VS: BP, HR, Temp
If patient is on magnesium sulfate for preeclampsia, note         FHT = baseline rate, variability, accels, decels  category I/II/III by
symptoms of preeclampsia as well as side effects and                 Doptone/EFM/FSE
toxicity of magnesium sulfate, e.g., HA, scotomata, RUQ           Contractions (CTX): freq, strength by palpation or IUPC on _ mu/min
pain, nausea, vomiting, blurry vision, dyspnea, chest             pitocin ?
pain, and weakness. Also include contractions, leaking            SVE: dilation/effacement/station/position SROM/AROM time, color of
of fluid, VB and FM.                                              fluid
O:                                                                A/P: __ y.o. G_P_ at __ wks for current labor status
BP (range if preeclampsia), pulse, temp, RR, I/Os                       1. Labor: current state, expectant management/plan
(running total as well as total over last shift), weight if             2. Fetal well-being (FWB): reassuring, continue to monitor or
applicable                                                                  if concening give mom O2/change position/dec pit/fluid
Exam- heart, lung, abd, ext with DTRs                                       bolus
FHTs and TOCO                                                           3. Pain: well controlled/plan
Labs- culture results, preeclampsia labs, etc                           4. Anything else: increased BP, increased Temp, etc.
A:                                                                Discussed with Dr. Attending
22 year old G1P0 at 32.2 weeks by L= US 12
HD # 4 s/p admission for preeclampsia/preterm labor-no
contractions on Magnesium sulfate at 2gm/hr, no                   If Pre-eclapmtic, add:
evidence of infection or magnesium toxicity, good urine           S: Headache, vision changes, epigastric pain, SOB
output, on PCN day # 2 for GBS prophylaxis, culture               O: lungs, urine output, DTR’s/clonus
pending                                                           Labs: CBC w/ platelets & preeclmapsia panel (AST/ALT/Uric
P:                                                                Acid/LDH/urine prot/cr ratio)
Continue magnesium sulfate until 24h after second dose
of betamethasone
(or 24h after delivery if preeclampsia)
Follow for signs and symptoms of magnesium toxicity or
infection
Check cultures/follow labs etc.


Normal Vaginal Delivery Note
                                                                  Vacuum-assisted Delivery Note
                                                                  __ y.o. G_P_ s/p vacuum-assisted VD/VBAC of m/f infant
At 2120 this 22 year old G2 now P2002 delivered a viable male     Preop dx
infant via normal spontaneous vaginal delivery under epidural     Post-op Dx
anesthesia. The infant delivered in ROA position over intact
perineum. Nuchal cord x 1 was easily reduced. The infant
                                                                  Indication: prolonged2nd stage; inadequate maternal effort, etc
was bulb suctioned at the perineum. The cord was clamped          SVE: fully dilated @ station +3 in __OA position
and cut and the infant was place in the warmer. Placenta was      Decision was made to apply the Kiwi vacuum @ ___ (time) for the
delivered spontaneously and intact with 3 vessel cord. The        above indications. The edges of the cup of the Kiwi vacuum were
fundus was firm with massage and IV Pitocin. There were no        placed approx 3cm from the anterior fontanelle, and just at the edge
cervical, vaginal, or perineal lacerations. Male infant weights   of the posterior fontanelle. The center of the cup was placed over
3486g, 7# 12oz, and APGARS 8 at 1 minute and 9 at 5               the flexion point. The edges of the cup were swept with a finger to
minutes. EBL is 250mL. Excellent hemostasis is noted.             ensure that no maternal tissues were entrapped.
Mother and infant were transferred to postpartum in stable        After correct placement of the cup was confirmed, vacuum pressure
condition. Dr. Attending was present for the delivery and Dr.
Resident and Dr. Medical student assisted with the delivery:
                                                                  was raised to 500-600 mmHg. Gentle traction along the axis of the
                                                                  pelvic curve (i.e., down then up), was applied in concert with
Other information to add:                                         maternal pushing. ___ # applications. ___ # popoffs.
If positive meconium, mention NICU present.                       The baby’s head was delivered and gentle traction was applied to
If shoulder dystocia: document maneuvers used in order and        deliver the anterior shoulders and the rest of the body. (nuchal cord)
check with nurses on recorded clock times for consistent          The cord was double clamped and cut. Cord pH sample sent. The
documentation. Document total time on perineum.                   placenta was then delivered spontaneously. Pitocin 20 units in 1L
If laceration, document degree, repair, suture used and           LR was initiated. The vagina and perineal areas were inspected for
anesthesia.                                                       lacerations and repaired ___. Hemostasis was assured and required
If uterine atony, note blood loss, and medications/procedures
                                                                  repairs performed
used to control bleeding.
If forceps or vacuum, document verbal consent, placement-         EBL = ___
station and position of head and instrument on head, number       Complications: __
of pop-offs, total pressure used and total instrument time.       Inspection of vaginal walls and rectum completed
                                                                  Mother and infant in room, doing well
                                                                  Dr. Attending present for delivery
                                                                            Post-Partum/Post-Op Note
OB Discharge Dictation                                                      S:
Patient Name                                                                Amount of lochia, voiding, walking, flatus, BM, N/V,
Patient MR#                                                                 breast/bottlefeeding with or without difficulty
Resident Name                                                               If preeclamptic: HA, scotomata, RUQ pain
Attending Name                                                              If postpartum hemorrhage: dizziness, dyspnea, chest palpitations
Date of Admission:                                                          O:
Date of Discharge:                                                          Vital signs T and Tmax, P RR, BP (include ranges) I/O on all postop or
Admitting Diagnosis:                                                        preeclamptic patients, orthostatics for bleeding
      1. IUP at __ weeks and __ days                                        Lungs- CTAB
      2. Diagnosis on admission: ( preeclampsia, PTL, spontaneous           CV-RRR
            labor, PPROM)                                                   ABD- Fundus location, firmness, tenderness, and location of fundus (at
      3. Other diagnoses: (all other medical problems present at            or below umbilicus)
            admission, including diabetes, hypertension, fetal anomalies,   Incision- clean, dry, intact
            anemia, obesity, etc)                                           Ext- edema, DTRs, calf pain
Discharge Diagnosis:                                                        Breast exam
      1. IUP at __ weeks and __ days                                        Perineal exam- for severe swelling or hematoma
      2. Diagnosis on admission: (after each diagnosis, resolved,           Labs:
            improved, treated, or remove diagnosis if ruled out)            A:
      3. Other diagnoses: (all other medical problems present at            24 year old now G2P2022, s/p NSVD doing well PPD#2
            time of discharge)                                              Prenatal labs: WNL, or Rubella Nonimmune, or Rh negative.
*Need to specify if there is a change in primary diagnosis from             Breast or bottlefeeding
admission to discharge, (mild preeclampsia to HELLP syndrome)               Other:
Procedures Performed: EFM, ultrasound, epidural, vaginal delivery,          Please remember to add any issues from the past medical history/or
or cesarean section                                                         the labor!
Complications: transfusion reaction, bladder laceration, delivery           Severe preeclampsia: On Magnesium sulfate, no toxicity, diuresis, BP
lacerations, etc                                                            stable, no HELLP, asymptomatic
Consultations: Maternal fetal medicine, gastroenterology, cardiology,       Pyrexia: Tmax
etc                                                                         Postpartum hemorrhage: EBL__, H/H __, asymptomatic, not
History of Present Illness:                                                 orthostatic
Patient is a __ year old G_ P_/_/_/_ at __ weeks and __ days by LMP         Anemia: Symptoms, H/H__
= US at __ weeks. LMP:__/__/__, EDD: __/__/__. She presented to             Substance abuse
Sinai hospital with a complaint of ______. Describe presentation of         Pain well controlled
Illness, including evaluation and labs elsewhere. If transferred from
other facility, specify the name of the provider, hospital, and route of    P:
transfer, i.e., by helicopter, ambulance, etc.                              Routine postpartum care
PNC: Provider, facility or no prenatal care.                                Rx: Motrin, Percocet, Colace, Ferrous sulfate TID
Prenatal Labs: On admission and discharge                                   Micronor for contraception to start at 3 weeks
Past OB History:                                                            Discharge home
            Year of delivery, vaginal or cesarean, birth weight,            Vaginal rest, no heavy lifting
complications, location                                                     Follow up in 6 weeks at OBC clinic Dr. Attending
PMHx:
PSHx:
Social History:
Family History: Pertinent to HPI:
ROS: Pertinent to HPI                                                       Abbreviations
Hospital Care: What happened during her stay, how did we
                                                                            NSVD = Normal spontaneous vaginal delivery
diagnose/resolve each of her admitting diagnoses day by day during
hospitalization. (labs/tests/medications given)                             VAVD = vacuum extracted vaginal delivery
Disposition:                                                                FAVD = forceps assisted vaginal delivery
Discharge: Home, left AMA or other                                          LTCS = low transverse c-section
Follow up appointments: Where, when, and if patient needed to call
                                                                            AROM = artificial rupture of membranes
for appointment
Instructions: Activity, diet and precautions.                               SROM = spontaneous rupture of membranes
Discharge medications: include name, dose,                                  PAM = pt administered medication
frequency, and route. INCLUDE CONTRACEPTION if                              Lochia = vaginal bleeding
started in hospital (Depo)                                                  SCM = special care nursey
                                                                            EBL = estimated blood loss
Please state if face to face discharge planning time is greater than 30     NST = non-stress test = 2 accels 15 bpm over baseline w/in 20min
minutes as we can bill differently.                                         FHT: fetal heart tones
CC:                                                                         EFM: electronic fetal monitoring
Attending provider etc.                                                     FSE: fetal scalp electrode
                                                                            SVE: Sterile vaginal exam
                                                                            IUPC: internal uterine pressure catheter
                                                                 VITAL SIGNS: BP_/_ , Pulse __, Height __ , Weight ___
History and Physical                                             pounds
Patient Name                                                     GENERAL APEARANCE: The patient is a pleasant, normal
Patient Medical Record Number                                    appearing female with normal affect and in no distress.
Resident Name                                                    NECK: supple. No cervical lymphadenopathy. No
Attending Name
                                                                 thyromegaly, no nodules palpated, trachea midline.
Date of Service
                                                                 LUNGS: Clear bilaterally with normal respiratory effort
CC: Here for                                                     HEART: Regular rate and rhythm. No murmurs noted.
HPI: Pt is a __ year old G_P_/_/_/_ alert female who presents    Pulses are full and symmetrical.
today at __ weeks by LMP equal to her US at __ weeks. EDD:       BREASTS: Breast exam performed seated and supine. No
__/__/__.                                                        masses, non-tender, no nipple discharge or lymphadenopathy.
(To bill a comprehensive you need 4 elements in your HPI)        ABDOMEN: Soft, non-tender, non-distended. No
LMP:                                                             hepatosplenomegaly. Normal bowel sounds. No umbilical or
PNC: Dr. Attending                                               inguinal hernias.
                                                                 SKIN: Warm and dry to touch. No lesions or rashes noted.
ALLERGIES:                                                       PSYCHIATRIC/NEUROLOGIC: Appropriate mood and affect,
MEDICATIONS: include name, dose, frequency, and route            normal recall, alert and oriented x 3
PMHx:                                                            EXTREMITIES: Warm and well perfused. No edema noted.
PSHx:                                                            Muscle strength and sensation are normal bilaterally 5/5 in
SOCIAL Hx: Alcohol, drug, cigarette, caffeine use, exercise,     both upper and lower extremities.
employment, living arrangements, marital status, father of the   GU:
baby                                                             Vulva: Inspection of her external genitalia reveals normal mons
FAMILY Hx:                                                       pubis, labia minora and labia majora. Normal appearing
OB Hx: Year of delivery, vaginal or cesarean, birth weight,      clitoris, urethral meatus and Skene's glands.
complications, location                                          Bladder: No evidence of urethral or bladder tenderness.
Gyn Hx: Menarche/frequency/duration/amount menses,               Vagina: Speculum exam reveals pink and moist vaginal
history of STDs, history of abnormal Pap smears, on              mucosa. Bartholin gland is normal to palpation.
contraception.                                                   Cervix: Cervix is normal in appearance with no lesions. There
                                                                 is no cervical motion tenderness.
Past medical, family, and social must be documented for a        Uterus: Uterus is normal size, mobile and non-tender. No
comprehensive!                                                   adnexal masses are palpated. Adnexae are non-tender to
                                                                 palpation
ROS: (this is an 11 point ROS- comprehensive. You cannot         Perineum: Perineum appears normal other than previous
state” a 10 point review of systems was performed and was        above notation.
negative- you need to document at least 1 element from all       Anus: Normal with no apparent lesions.
areas)
Constitutional: Denies Headache. No weight changes. No           LAB: all admitting lab values
fevers or chills.                                                RADIOLOGY: all radiology results
HEENT: Denies vision changes or hearing changes. No sinus
                                                                 ASSESSMENT:
problems.                                                        __year old G _P _/_/_/_ at __ weeks by L equal to US at __
Breasts: Denies breast masses, pain or nipple discharge.         weeks
Respiratory: No breathing issues, cough or shortness of          Chief complaint
breath                                                           Do not forget anemia, thrombocytopenia, all other diagnoses
Cardiovascular: Denies chest pain, syncope or palpitations.      from history!
GI: Denies nausea, vomiting, diarrhea, or constipation
                                                                 PLAN:
Endocrine: Denies hot flashes, night sweats, heat or cold        Admit to Labor and Delivery
intolerance.                                                     IV LR at 125cc/hr
Hematologic: Denies easy bruising or bleeding disorders.         Expectant management
Allergies/Immunologic: Denies seasonal allergies or any          Continuous EFM with Toco
history of immunologic disorders                                 Desires BTL
Neurologic: Normal sensation and motor control. No history of    Plans to breastfeed
                                                                 Desires IUD at 6 week postpartum visit
seizures or syncope.
Musculoskeletal: Denies joint pain, swelling, or erythema
Skin: Denies rashes, significant lesions or pruritis.            The best documented assessment and plan has a plan to
Psychiatric: Denies anxiety, depression, memory deficits, and    match each assessment
appetite or sleep changes.

PHYSICAL EXAM: ( you need to document at least: vitals,
abdomen and this entire GU to get a comprehensive exam- at
least 2 elements from 9 areas)
Consultation:                                                            NECK: supple. No cervical lymphadenopathy. No thyromegaly, no
                                                                         nodules palpated, trachea midline.
Patient Name
Medical Record Number                                                    LUNGS: Clear bilaterally with normal respiratory effort
Resident Name                                                            HEART: Regular rate and rhythm. No murmurs noted. Pulses are
Attending Name                                                           full and symmetrical.
Date of Service
Service: OB/GYN                                                          BREASTS: Breast exam performed seated and supine. No masses,
                                                                         non-tender, no nipple discharge or lymphadenopathy.
Reason for Consultation: RLQ pain and amenorrhea                         ABDOMEN: Soft, tender over the right lower quadrant, non-distended.
CC: Pain and vaginal bleeding                                            No hepatosplenomegaly. Normal bowel sounds. No umbilical or
HPI: Pt is a __ year old G_P_/_/_/_ alert female who presents today at   inguinal hernias. Positive rebound and guarding.
__ weeks by LMP of _____ equal to her US at __ weeks. EDD:               SKIN: Warm and dry to touch. No lesions or rashes noted.
__/__/__. She presents with chief complaint of right lower quadrant      PSYCHIATRIC/NEUROLOGIC: Appropriate mood and affect, normal
pain that began suddenly 2 days prior. Describe quality, quantity,       recall, alert and oriented x 3
location, duration, associated factors, allieviating factors, previous   EXTREMITIES: Warm and well perfused. No edema noted. Muscle
episodes of the same type. Pain scale.                                   strength and sensation are normal bilaterally 5/5 in both upper and
(4+ modifying factors-detailed or comprehensive HPI)                     lower extremities.
LMP:                                                                     GU:
PNC:                                                                     Vulva: Inspection of her external genitalia reveals normal mons pubis,
ALLERGIES:                                                               labia minora and labia majora. Normal appearing clitoris, urethral
MEDICATIONS: include name, dose, frequency, and route                    meatus and Skene's glands.
PMHx:                                                                    Bladder: No evidence of urethral or bladder tenderness.
PSHx:                                                                    Vagina: Speculum exam reveals pink and moist vaginal mucosa.
SOCIAL Hx: Alcohol, drug, cigarette, caffeine use, exercise,             Bartholin gland is normal to palpation.
employment, living arrangements, marital status, father of the baby      Cervix: Cervix is normal in appearance with no lesions. There is no
FAMILY Hx:                                                               cervical motion tenderness.
OB Hx: Year of delivery, vaginal or cesarean, birth weight,              Uterus: Uterus is normal size, mobile and non-tender. No adnexal
complications, location                                                  masses are palpated. Adnexae are non-tender to palpation
Gyn Hx: Menarche/frequency/duration/amount menses, history of            Perineum: Perineum appears normal other than previous above
STDs, history of abnormal Pap smears, on _______ for contraception.      notation.
(Past medical, family, and social must be documented for a               Anus: Normal with no apparent lesions.
comprehensive!)
                                                                         LAB: all available lab values
ROS: (this is an 11 point ROS- comprehensive. You cannot state” a        RADIOLOGY: all radiology results
10 point review of systems was performed and was negative- you need
                                                                         ASSESSMENT:
to document at least 1 element from all areas)
                                                                         __year old G _P _/_/_/_ at __ weeks by L equal to US at __ weeks
Constitutional: Denies Headache. No weight changes. No fevers or         Unplanned pregnancy
chills.                                                                  Right lower quadrant pain- ectopic pregnancy vs. early IUP vs.
HEENT: Denies vision changes or hearing changes. No sinus                threatened AB
                                                                         Vaginal spotting
problems.                                                                Insulin dependent diabetes
Breasts: Denies breast masses, pain or nipple discharge.                 List all other PMHx
Respiratory: No breathing issues, cough or shortness of breath           Do not forget anemia, thrombocytopenia, all other diagnoses from
                                                                         history!
Cardiovascular: Denies chest pain, syncope or palpitations.
GI: Denies nausea, vomiting, diarrhea, or constipation                   PLAN:
Endocrine: Denies hot flashes, night sweats, heat or cold intolerance.   Admit to Floor
                                                                         IV LR at 125cc/hr
Hematologic: Denies easy bruising or bleeding disorders.
                                                                         Repeat quant hcg in 24h
Allergies/Immunologic: Denies seasonal allergies or any history of       Monitor for signs and symptoms of worsening pain
immunologic disorders                                                    Sliding scale insulin
Neurologic: Normal sensation and motor control. No history of            IV pain medication
                                                                         NPO
seizures or syncope.
Musculoskeletal: Denies joint pain, swelling, or erythema
Skin: Denies rashes, significant lesions or pruritis.                    The best documented assessment and plan has a plan to match each
                                                                         assessment. There should be at least 3 points for comprehensive
Psychiatric: Denies anxiety, depression, memory deficits, and appetite   99244 or 99254 and at least 4 for 99245 or 99255.
or sleep changes.

                                                                         ER consult most likely 99244
PHYSICAL EXAM: (you need to document at least: vitals, abdomen
                                                                         In patient consult most likely 99254
and this entire GU to get a comprehensive exam- at least 2 elements
from 9 areas)
VITAL SIGNS: BP_/_ , Pulse __, Height __ , Weight ___ pounds
GENERAL APEARANCE: The patient is a pleasant, normal appearing
female with normal affect and in no distress.

				
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posted:11/12/2011
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