Download Post-Partum/Post

Magnesium Sulfate Check Note
S:
If patient is on magnesium sulfate for preeclampsia, note
symptoms of preeclampsia as well as side effects and
toxicity of magnesium sulfate, e.g., HA, scotomata, RUQ
pain, nausea, vomiting, blurry vision, dyspnea, chest
pain, and weakness. Also include contractions, leaking
of fluid, VB and FM.
O:
BP (range if preeclampsia), pulse, temp, RR, I/Os
(running total as well as total over last shift), weight if
applicable
Exam- heart, lung, abd, ext with DTRs
FHTs and TOCO
Labs- culture results, preeclampsia labs, etc
A:
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
evidence of infection or magnesium toxicity, good urine
output, on PCN day # 2 for GBS prophylaxis, culture
pending
P:
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.
L & D Progress Note
S: Pt comfort level
O: Maternal VS: BP, HR, Temp
FHT = baseline rate, variability, accels, decels  category I/II/III by
Doptone/EFM/FSE
Contractions (CTX): freq, strength by palpation or IUPC on _ mu/min
pitocin ?
SVE: dilation/effacement/station/position SROM/AROM time, color of
fluid
A/P: __ y.o. G_P_ at __ wks for current labor status
1. Labor: current state, expectant management/plan
2. Fetal well-being (FWB): reassuring, continue to monitor or
if concening give mom O2/change position/dec pit/fluid
bolus
3. Pain: well controlled/plan
4. Anything else: increased BP, increased Temp, etc.
Discussed with Dr. Attending
If Pre-eclapmtic, add:
S: Headache, vision changes, epigastric pain, SOB
O: lungs, urine output, DTR’s/clonus
Labs: CBC w/ platelets & preeclmapsia panel (AST/ALT/Uric
Acid/LDH/urine prot/cr ratio)
Normal Vaginal Delivery Note
At 2120 this 22 year old G2 now P2002 delivered a viable male
infant via normal spontaneous vaginal delivery under epidural
anesthesia. The infant delivered in ROA position over intact
perineum. Nuchal cord x 1 was easily reduced. The infant
was bulb suctioned at the perineum. The cord was clamped
and cut and the infant was place in the warmer. Placenta was
delivered spontaneously and intact with 3 vessel cord. The
fundus was firm with massage and IV Pitocin. There were no
cervical, vaginal, or perineal lacerations. Male infant weights
3486g, 7# 12oz, and APGARS 8 at 1 minute and 9 at 5
minutes. EBL is 250mL. Excellent hemostasis is noted.
Mother and infant were transferred to postpartum in stable
condition. Dr. Attending was present for the delivery and Dr.
Resident and Dr. Medical student assisted with the delivery:
Other information to add:
If positive meconium, mention NICU present.
If shoulder dystocia: document maneuvers used in order and
check with nurses on recorded clock times for consistent
documentation. Document total time on perineum.
If laceration, document degree, repair, suture used and
anesthesia.
If uterine atony, note blood loss, and medications/procedures
used to control bleeding.
If forceps or vacuum, document verbal consent, placementstation and position of head and instrument on head, number
of pop-offs, total pressure used and total instrument time.
Vacuum-assisted Delivery Note
__ y.o. G_P_ s/p vacuum-assisted VD/VBAC of m/f infant
Preop dx
Post-op Dx
Indication: prolonged2nd stage; inadequate maternal effort, etc
SVE: fully dilated @ station +3 in __OA position
Decision was made to apply the Kiwi vacuum @ ___ (time) for the
above indications. The edges of the cup of the Kiwi vacuum were
placed approx 3cm from the anterior fontanelle, and just at the edge
of the posterior fontanelle. The center of the cup was placed over
the flexion point. The edges of the cup were swept with a finger to
ensure that no maternal tissues were entrapped.
After correct placement of the cup was confirmed, vacuum pressure
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
maternal pushing. ___ # applications. ___ # popoffs.
The baby’s head was delivered and gentle traction was applied to
deliver the anterior shoulders and the rest of the body. (nuchal cord)
The cord was double clamped and cut. Cord pH sample sent. The
placenta was then delivered spontaneously. Pitocin 20 units in 1L
LR was initiated. The vagina and perineal areas were inspected for
lacerations and repaired ___. Hemostasis was assured and required
repairs performed
EBL = ___
Complications: __
Inspection of vaginal walls and rectum completed
Mother and infant in room, doing well
Dr. Attending present for delivery
OB Discharge Dictation
Patient Name
Patient MR#
Resident Name
Attending Name
Date of Admission:
Date of Discharge:
Admitting Diagnosis:
1. IUP at __ weeks and __ days
2. Diagnosis on admission: ( preeclampsia, PTL, spontaneous
labor, PPROM)
3. Other diagnoses: (all other medical problems present at
admission, including diabetes, hypertension, fetal anomalies,
anemia, obesity, etc)
Discharge Diagnosis:
1. IUP at __ weeks and __ days
2. Diagnosis on admission: (after each diagnosis, resolved,
improved, treated, or remove diagnosis if ruled out)
3. Other diagnoses: (all other medical problems present at
time of discharge)
*Need to specify if there is a change in primary diagnosis from
admission to discharge, (mild preeclampsia to HELLP syndrome)
Procedures Performed: EFM, ultrasound, epidural, vaginal delivery,
or cesarean section
Complications: transfusion reaction, bladder laceration, delivery
lacerations, etc
Consultations: Maternal fetal medicine, gastroenterology, cardiology,
etc
History of Present Illness:
Patient is a __ year old G_ P_/_/_/_ at __ weeks and __ days by LMP
= US at __ weeks. LMP:__/__/__, EDD: __/__/__. She presented to
Sinai hospital with a complaint of ______. Describe presentation of
Illness, including evaluation and labs elsewhere. If transferred from
other facility, specify the name of the provider, hospital, and route of
transfer, i.e., by helicopter, ambulance, etc.
PNC: Provider, facility or no prenatal care.
Prenatal Labs: On admission and discharge
Past OB History:
Year of delivery, vaginal or cesarean, birth weight,
complications, location
PMHx:
PSHx:
Social History:
Family History: Pertinent to HPI:
ROS: Pertinent to HPI
Hospital Care: What happened during her stay, how did we
diagnose/resolve each of her admitting diagnoses day by day during
hospitalization. (labs/tests/medications given)
Disposition:
Discharge: Home, left AMA or other
Follow up appointments: Where, when, and if patient needed to call
for appointment
Instructions: Activity, diet and precautions.
Discharge medications: include name, dose,
frequency, and route. INCLUDE CONTRACEPTION if
started in hospital (Depo)
Please state if face to face discharge planning time is greater than 30
minutes as we can bill differently.
CC:
Attending provider etc.
Post-Partum/Post-Op Note
S:
Amount of lochia, voiding, walking, flatus, BM, N/V,
breast/bottlefeeding with or without difficulty
If preeclamptic: HA, scotomata, RUQ pain
If postpartum hemorrhage: dizziness, dyspnea, chest palpitations
O:
Vital signs T and Tmax, P RR, BP (include ranges) I/O on all postop or
preeclamptic patients, orthostatics for bleeding
Lungs- CTAB
CV-RRR
ABD- Fundus location, firmness, tenderness, and location of fundus (at
or below umbilicus)
Incision- clean, dry, intact
Ext- edema, DTRs, calf pain
Breast exam
Perineal exam- for severe swelling or hematoma
Labs:
A:
24 year old now G2P2022, s/p NSVD doing well PPD#2
Prenatal labs: WNL, or Rubella Nonimmune, or Rh negative.
Breast or bottlefeeding
Other:
Please remember to add any issues from the past medical history/or
the labor!
Severe preeclampsia: On Magnesium sulfate, no toxicity, diuresis, BP
stable, no HELLP, asymptomatic
Pyrexia: Tmax
Postpartum hemorrhage: EBL__, H/H __, asymptomatic, not
orthostatic
Anemia: Symptoms, H/H__
Substance abuse
Pain well controlled
P:
Routine postpartum care
Rx: Motrin, Percocet, Colace, Ferrous sulfate TID
Micronor for contraception to start at 3 weeks
Discharge home
Vaginal rest, no heavy lifting
Follow up in 6 weeks at OBC clinic Dr. Attending
Abbreviations
NSVD = Normal spontaneous vaginal delivery
VAVD = vacuum extracted vaginal delivery
FAVD = forceps assisted vaginal delivery
LTCS = low transverse c-section
AROM = artificial rupture of membranes
SROM = spontaneous rupture of membranes
PAM = pt administered medication
Lochia = vaginal bleeding
SCM = special care nursey
EBL = estimated blood loss
NST = non-stress test = 2 accels 15 bpm over baseline w/in 20min
FHT: fetal heart tones
EFM: electronic fetal monitoring
FSE: fetal scalp electrode
SVE: Sterile vaginal exam
IUPC: internal uterine pressure catheter
History and Physical
Patient Name
Patient Medical Record Number
Resident Name
Attending Name
Date of Service
CC: Here for
HPI: Pt is a __ year old G_P_/_/_/_ alert female who presents
today at __ weeks by LMP equal to her US at __ weeks. EDD:
__/__/__.
(To bill a comprehensive you need 4 elements in your HPI)
LMP:
PNC: Dr. Attending
ALLERGIES:
MEDICATIONS: include name, dose, frequency, and route
PMHx:
PSHx:
SOCIAL Hx: Alcohol, drug, cigarette, caffeine use, exercise,
employment, living arrangements, marital status, father of the
baby
FAMILY Hx:
OB Hx: Year of delivery, vaginal or cesarean, birth weight,
complications, location
Gyn Hx: Menarche/frequency/duration/amount menses,
history of STDs, history of abnormal Pap smears, on
contraception.
Past medical, family, and social must be documented for a
comprehensive!
ROS: (this is an 11 point ROS- comprehensive. You cannot
state” a 10 point review of systems was performed and was
negative- you need to document at least 1 element from all
areas)
Constitutional: Denies Headache. No weight changes. No
fevers or chills.
HEENT: Denies vision changes or hearing changes. No sinus
problems.
Breasts: Denies breast masses, pain or nipple discharge.
Respiratory: No breathing issues, cough or shortness of
breath
Cardiovascular: Denies chest pain, syncope or palpitations.
GI: Denies nausea, vomiting, diarrhea, or constipation
Endocrine: Denies hot flashes, night sweats, heat or cold
intolerance.
Hematologic: Denies easy bruising or bleeding disorders.
Allergies/Immunologic: Denies seasonal allergies or any
history of immunologic disorders
Neurologic: Normal sensation and motor control. No history of
seizures or syncope.
Musculoskeletal: Denies joint pain, swelling, or erythema
Skin: Denies rashes, significant lesions or pruritis.
Psychiatric: Denies anxiety, depression, memory deficits, and
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)
VITAL SIGNS: BP_/_ , Pulse __, Height __ , Weight ___
pounds
GENERAL APEARANCE: The patient is a pleasant, normal
appearing female with normal affect and in no distress.
NECK: supple. No cervical lymphadenopathy. No
thyromegaly, no nodules palpated, trachea midline.
LUNGS: Clear bilaterally with normal respiratory effort
HEART: Regular rate and rhythm. No murmurs noted.
Pulses are full and symmetrical.
BREASTS: Breast exam performed seated and supine. No
masses, non-tender, no nipple discharge or lymphadenopathy.
ABDOMEN: Soft, non-tender, non-distended. No
hepatosplenomegaly. Normal bowel sounds. No umbilical or
inguinal hernias.
SKIN: Warm and dry to touch. No lesions or rashes noted.
PSYCHIATRIC/NEUROLOGIC: Appropriate mood and affect,
normal recall, alert and oriented x 3
EXTREMITIES: Warm and well perfused. No edema noted.
Muscle strength and sensation are normal bilaterally 5/5 in
both upper and lower extremities.
GU:
Vulva: Inspection of her external genitalia reveals normal mons
pubis, labia minora and labia majora. Normal appearing
clitoris, urethral meatus and Skene's glands.
Bladder: No evidence of urethral or bladder tenderness.
Vagina: Speculum exam reveals pink and moist vaginal
mucosa. Bartholin gland is normal to palpation.
Cervix: Cervix is normal in appearance with no lesions. There
is no cervical motion tenderness.
Uterus: Uterus is normal size, mobile and non-tender. No
adnexal masses are palpated. Adnexae are non-tender to
palpation
Perineum: Perineum appears normal other than previous
above notation.
Anus: Normal with no apparent lesions.
LAB: all admitting lab values
RADIOLOGY: all radiology results
ASSESSMENT:
__year old G _P _/_/_/_ at __ weeks by L equal to US at __
weeks
Chief complaint
Do not forget anemia, thrombocytopenia, all other diagnoses
from history!
PLAN:
Admit to Labor and Delivery
IV LR at 125cc/hr
Expectant management
Continuous EFM with Toco
Desires BTL
Plans to breastfeed
Desires IUD at 6 week postpartum visit
The best documented assessment and plan has a plan to
match each assessment
Consultation:
Patient Name
Medical Record Number
Resident Name
Attending Name
Date of Service
Service: OB/GYN
Reason for Consultation: RLQ pain and amenorrhea
CC: Pain and vaginal bleeding
HPI: Pt is a __ year old G_P_/_/_/_ alert female who presents today at
__ weeks by LMP of _____ equal to her US at __ weeks. EDD:
__/__/__. She presents with chief complaint of right lower quadrant
pain that began suddenly 2 days prior. Describe quality, quantity,
location, duration, associated factors, allieviating factors, previous
episodes of the same type. Pain scale.
(4+ modifying factors-detailed or comprehensive HPI)
LMP:
PNC:
ALLERGIES:
MEDICATIONS: include name, dose, frequency, and route
PMHx:
PSHx:
SOCIAL Hx: Alcohol, drug, cigarette, caffeine use, exercise,
employment, living arrangements, marital status, father of the baby
FAMILY Hx:
OB Hx: Year of delivery, vaginal or cesarean, birth weight,
complications, location
Gyn Hx: Menarche/frequency/duration/amount menses, history of
STDs, history of abnormal Pap smears, on _______ for contraception.
(Past medical, family, and social must be documented for a
comprehensive!)
ROS: (this is an 11 point ROS- comprehensive. You cannot state” a
10 point review of systems was performed and was negative- you need
to document at least 1 element from all areas)
Constitutional: Denies Headache. No weight changes. No fevers or
chills.
HEENT: Denies vision changes or hearing changes. No sinus
problems.
Breasts: Denies breast masses, pain or nipple discharge.
Respiratory: No breathing issues, cough or shortness of breath
Cardiovascular: Denies chest pain, syncope or palpitations.
GI: Denies nausea, vomiting, diarrhea, or constipation
Endocrine: Denies hot flashes, night sweats, heat or cold intolerance.
Hematologic: Denies easy bruising or bleeding disorders.
Allergies/Immunologic: Denies seasonal allergies or any history of
immunologic disorders
Neurologic: Normal sensation and motor control. No history of
seizures or syncope.
Musculoskeletal: Denies joint pain, swelling, or erythema
Skin: Denies rashes, significant lesions or pruritis.
Psychiatric: Denies anxiety, depression, memory deficits, and 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)
VITAL SIGNS: BP_/_ , Pulse __, Height __ , Weight ___ pounds
GENERAL APEARANCE: The patient is a pleasant, normal appearing
female with normal affect and in no distress.
NECK: supple. No cervical lymphadenopathy. No thyromegaly, no
nodules palpated, trachea midline.
LUNGS: Clear bilaterally with normal respiratory effort
HEART: Regular rate and rhythm. No murmurs noted. Pulses are
full and symmetrical.
BREASTS: Breast exam performed seated and supine. No masses,
non-tender, no nipple discharge or lymphadenopathy.
ABDOMEN: Soft, tender over the right lower quadrant, non-distended.
No hepatosplenomegaly. Normal bowel sounds. No umbilical or
inguinal hernias. Positive rebound and guarding.
SKIN: Warm and dry to touch. No lesions or rashes noted.
PSYCHIATRIC/NEUROLOGIC: Appropriate mood and affect, normal
recall, alert and oriented x 3
EXTREMITIES: Warm and well perfused. No edema noted. Muscle
strength and sensation are normal bilaterally 5/5 in both upper and
lower extremities.
GU:
Vulva: Inspection of her external genitalia reveals normal mons pubis,
labia minora and labia majora. Normal appearing clitoris, urethral
meatus and Skene's glands.
Bladder: No evidence of urethral or bladder tenderness.
Vagina: Speculum exam reveals pink and moist vaginal mucosa.
Bartholin gland is normal to palpation.
Cervix: Cervix is normal in appearance with no lesions. There is no
cervical motion tenderness.
Uterus: Uterus is normal size, mobile and non-tender. No adnexal
masses are palpated. Adnexae are non-tender to palpation
Perineum: Perineum appears normal other than previous above
notation.
Anus: Normal with no apparent lesions.
LAB: all available lab values
RADIOLOGY: all radiology results
ASSESSMENT:
__year old G _P _/_/_/_ at __ weeks by L equal to US at __ weeks
Unplanned pregnancy
Right lower quadrant pain- ectopic pregnancy vs. early IUP vs.
threatened AB
Vaginal spotting
Insulin dependent diabetes
List all other PMHx
Do not forget anemia, thrombocytopenia, all other diagnoses from
history!
PLAN:
Admit to Floor
IV LR at 125cc/hr
Repeat quant hcg in 24h
Monitor for signs and symptoms of worsening pain
Sliding scale insulin
IV pain medication
NPO
The best documented assessment and plan has a plan to match each
assessment. There should be at least 3 points for comprehensive
99244 or 99254 and at least 4 for 99245 or 99255.
ER consult most likely 99244
In patient consult most likely 99254