Post-partum template note example

Subjective: [Feeling well with no acute complaints.] Pain [well] managed, [tolerating] PO, [ambulating without difficulty], voiding [spontaneously][appropriately via Foley][, and passing flatus]. Lochia [appropriate], and she denies [symptoms of anemia]. [Breast][Formula ]feeding and [declines][is undecided about] contraception.

Objective:

[INSERT VITALS: data format--> range and last documented]

Physical Exam

General: [No acute distress]

Cardiac: [Regular rate][ and rhythm][, no clinically significant murmur]

Lungs: [Aerating well, no respiratory distress][, clear to auscultation]

Abdomen: [Soft, no abnormal tenderness, no guarding, no rebound tenderness][, normal bowel sounds present]

[Incision: Dressing clean/dry/intact, edges well-approximated]

Fundus: [Firm, ][below] the umbilicus

Lower extremities: [No] edema, [no] calf tenderness

Neuro: [Alert, normal speech]

Psych: [Appropriate] mood and affect

Urine Output: [] mL/hr

[INSERT LABS]

Assessment:

Patient is a []-year-old G[]P[] s/p [SVD][RLTCD][1LTCD][ with Pfannenstiel][ with midline vertical] at [] []/7 wga[ due to][]. Patient is clinically stable and recovering appropriately on [PPD][][POD][].

2. [problem list]

3. [problem list]

4. [problem list]

[5]. [Breast][Formula ]feeding

[6]. [] for contraception

[7]. [Desires circumcision of baby]

[8]. [Gardasil vaccination status]

Plan:

- Routine postpartum care

- Pain control: [ibuprofen,][ acetaminophen][, gabapentin, oxycodone prn]

[- Follow up AM CBC]

[- Discontinue Foley and IV fluids on POD1]

- Advance diet as tolerated

[- Gardasil vaccination counseling performed]

[- Rhogam on d/c]

[- Iron on d/c]

[- DMPA on d/c]

[- Remove staples prior to d/c]

[- Circumcision of baby prior to d/c]