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Progress Notes Page 1 1/4/2003 PPD#1 0730 S/P NSVD, Female, 2° perineal lac., Breast-feeding. Feels generally well, but tired. No medical complaints. Voiding well. Baby doing well VS T=98.1, (Tmax=99.2), P=102, R=18, BP=100/65 Breasts soft, NT Abd: Uterus firm, at Umbil. + 2 FB, non-tender Calves: no tenderness Lochia: Moderate, non-foul Perineum: Intact Labs: CBC pending from this AM A/P: Stable PPD#1 Discussed contraception. Prefers OC’s. non-smoker. Rx for Triphasil 28s (3 packs) written Mike Hughey, MD PG-1 Note: These Progress Notes are for illustrative purposes only. Remember that: 1. Not all patients will present in this fashion. 2. Local customs may require significant modification of the Progress Note format and content.
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