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
(or 24h after delivery if preeclampsia)
Follow for signs and symptoms of magnesium toxicity or
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
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
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
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
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
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
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.
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
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
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.
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.
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.
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
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
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
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
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.