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RECT, ALWAYS, and NEVER.

If you nd one of these words, circle or underline it for later comparison with the answer. Evaluate each answer as being either true or false. Example: Which of the following is least likely to be associated with pelvic pain? A. endometriosis T B. ectopic pregnancy T C. ovarian cancer ? F D. ovarian torsion T By comparing the question, noting LEAST, to the answers, C is the best answer.

INTRODUCTION

SAMPLE PROGRESS NOTES AND ORDERS

Terminology G (gravidity) 3 = total number of pregnancies, including normal and abnormal intrauterine pregnancies, abortions, ectopic pregnancies, and hydatidiform moles (Remember, if patient was pregnant with twins, G = 1.) P (parity) 3 = number of deliveries > 500 grams or 24 weeks gestation, stillborn (dead) or alive (Remember, if patient was pregnant with twins, P = 1.) Ab (abortion) 0 = number of pregnancies that terminate < 24th gestational week or in which the fetus weighs < 500 grams LC (living children) 3 = number of successful pregnancy outcomes (Remember, if patient was pregnant with twins, LC = 2.) Or use the TPAL system if it is used at your medical school: T = number of term deliveries (3) P = number of preterm deliveries (0) A = number of abortions (0) L = number of living children (3)

S A M P L E O B S T E T R I C A D M I S S I O N H I S T O RY A N D P H Y S I C A L

Date Time Identication: 25 yo G3P2 Estimated gestational age (EGA): 38 5/7 weeks Last menstrual period (LMP): First day of LMP Estimated date of connement: Due date (specify how it was determined) by LMP or by ____ wk US (Sonograms are most accurate for dating EGA when done at < 20 weeks.) Chief complaint (CC): Uterine contractions (UCs) q 7 min since 0100 History of present illness (HPI): 25 yo G3P2 with an intrauterine pregnancy (IUP) at 38 5/7 wks GA, well dated by LMP (10/13/99) and US at 10 weeks GA, who presented to L&D with CC of uterine contractions q 7 min. Prenatal care (PNC) at Highland Hospital (12 visits, rst visit at 7 wks GA), uterine size = to dates, prenatal BP range 100126/6483. Problem list includes H/o + group B Streptococcus (GBS) and a +PPD with subsequent negative chest x-ray in 5/00. Pt admitted in early active labor with a vaginal exam (VE) 4/90/2.
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Past Obstetric History 92 NSVD @ term, wt 3,700 g, no complications 94 NSVD @ term, wt 3,900 g, postpartum hemorrhage Allergies: NKDA Medications: PNV, Fe Medical Hx: H/o asthma (asymptomatic 7 yrs), UTI 1 @ 30 wks s/p Macrobid 100 mg 7 d, neg PPD with subsequent neg CXR (5/00) Surgical Hx: Negative Social Hx: Negative Family Hx: MotherDM II, fatherHTN ROS: Bilateral low back pain PE General appearance: Alert and oriented (A&O), no acute distress (NAD) Vital signs: T, BP, P, R HEENT: No scleral icterus, pale conjunctiva Neck: Thyroid midline, no masses, no lymphadenopathy (LAD) Lungs: CTA bilaterally Back: No CVA tenderness Heart: II/VI SEM Breasts: No masses, symmetric Abdomen: Gravid, nontender Fundal height: 36 cm Estimated fetal weight (EFW): 3,500 g by Leopolds Presentation: Vertex Extremities: Mild lower extremity edema, nonpitting Pelvis: Adequate VE: Dilatation (4 cm)/effacement (90%)/station (2); sterile speculum exam (SSE)? (Nitrazine?, Ferning?, Pooling?); membranes intact US (L&D): Vertex presentation conrmed, anterior placenta, AFI = 13.2 Fetal monitor: Baseline FHR = 150, reactive. Toco = UCs q 5 min

INTRODUCTION

Labs Blood type: A+ Antibody screen: Neg Rubella: Immune HbsAg VDRL: Nonreactive FTA GC Chlamydia HIV: See prenatal records 1 hr GTT: 105 3 hr GTT PPD: + s/p neg CXR CXR: Neg 5/00 AFP: Neg x 3 Amnio PAP: NL Hgb/Hct Urine: + blood, protein, glucose, nitrite, 2 WBCs GBS: +

Assessment 1. Intrauterine pregancy @ 38 5/7 wks GA in early active labor 2. Group B strep + 3. H/o + PPD with subsequent CXR 5/00 4. H/o UTI @ 30 wks GA, s/p Rxresolved 5. H/o asthmastable 7 yrs, no meds Plan 1. 2. 3. 4. 5. 6. 7. Admit to L&D NPO except ice chips H&H, VDRL, and hold tube D5 LR TRA 125 cc/hr Ampicillin 2 g IV load, then 1 g IV q 4 hrs (for GBS) External fetal monitors (EFMs) Prep and enema

INTRODUCTION

S A M P L E D E L I V E RY N O T E

Always sign and date your notes. NSVD of viable male infant over an intact perineum @ 12:35 P.M., Apgars 8&9, wt 3,654 g without difculty. Position LOA, bulb suction, nuchal cord 1 reducible. Spontaneous delivery of intact 3-vessel cord placenta @ 12:47 P.M., fundal massage and pitocin initiated, fundus rm. 2nd-degree perineal laceration repaired under local anesthesia with 3-0 vicryl. Estimated blood loss (EBL) = 450 cc. Mom and baby stable. Doctors: Johnson & Feig.

S A M P L E P O S T PA R T U M N O T E

S: O:

A: P:

Pt ambulating, voiding, tolerating a regular diet Vitals Heart: RR without murmurs Lungs: CTA bilaterally Breasts: Nonengorged, colostrum expressed bilaterally Fundus: Firm, mildly tender to palpation, 1 ngerbreadth below umbilicus Lochia: Moderate amount, rubra Perineum: Intact, no edema Extremities: No edema, nontender Postpartum Hgb: 9.7 VDRL: NR S/p NSVD, PP day # 1progressing well, afebrile, stable Continue postpartum care

S A M P L E P O S T- N S V D D I S C H A R G E O R D E R S

INTRODUCTION

1. 2. 3. 4.

D/c pt home Pelvic rest 6 weeks Postpartum check in 4 weeks D/c meds: FeSO4 300 mg 1 tab PO tid, #90 (For Hgb < 10; opinions vary on when to give FE postpartum) Colace 100 mg 1 tab PO bid PRN no bowel movement, #60

SAMPLE POSTCESAREAN SECTION NOTE

S: O:

A: P:

Pt c/o abdominal pain, no atus, minimal ambulation Vitals I&O (urinary intake and output): Last 8 hrs = 750/695 Heart: RR without murmurs Lungs: CTA bilaterally Breasts: Nonengorged, no colostrum expressed Fundus: Firm, tender to palpation, 1 ngerbreadth above umbilicus; incision without erythema/edema; C/D/I (clean/dry/intact); normal abdominal bowel sounds (NABS) Lochia: Scant, rubra Perineum: Intact, Foley catheter in place Extremities: 1+ pitting edema bilateral LEs, nontender Postpartum Hgb: 11 VDRL: NR S/p primary low-transverse c/s secondary to arrest of descent, POD # 1 afebrile, + atus, stable 1. D/c Foley 2. Strict I&OCall HO if UO < 120 cc/4 hrs 3. Clear liquid diet 4. Heplock IV once patient tolerates clears 5. Ambulate qid 6. Incentive spirometry 10/hr 7. Tylenol #3 2 tabs PO q 4 hrs PRN pain

SAMPLE DISCHARGE ORDERS POSTCESAREAN SECTION

1. 2. 3. 4.

D/c patient home Pelvic rest 4 weeks Incision check in 1 week Discharge meds: Tylenol #3 12 tabs PO q 4 hrs PRN pain, #30 Colace 100 mg 1 tab PO bid, #60

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