2-hour postpartum & post-op check

2-hour Postpartum & Post-Operative Check

Background: Patient is a [ ]-year-old G[ ]P[ ] s/p [SVD][RLTCD][1LTCD][myomectomy][hysterectomy][BTL] at [ ] [ ]/7 wga after presenting in [].

Subjective: Patient is [feeling well] at [2-hour postpartum] [2-hour post-op] check. Her pain is [adequately controlled]. Patient has [not yet] tolerated PO or ambulated. Voiding [spontaneously] [clear urine via foley]. Lochia [appropriate.] [Baby is doing well and bonding with mother.]

Objective:

[INSERT VITALS: Data Formats → "Vital Signs - Last 24 HR Range" +  "Vital Signs - Last Documented"]

Physical Exam General: [no acute distress] Cardiac: regular rate[ and rhythm], warm and well perfused[, no clinically sig murmur] Lungs: [aerating well, no respiratory distress, symmetric expansion][, clear to auscultation] Abdomen: soft, no abnormal tenderness, no guarding [Incision: overlying bandage clean, dry, intact] Fundus: [firm, ][below] the umbilicus Lower extremities: [no][trace] edema, [no] calf tenderness

UOP []mL/hr

Assessment: Patient is a [ ]-year-old G[ ]P[ ] s/p [SVD][RLTCD][1LTCD][myomectomy][hysterectomy][BTL] at [ ] [ ]/7 wga after presenting in []. Patient is clinically and hemodynamically stable and recovering appropriately in the immediate post[partum][operative] period.

Plan: - Plan to transfer to [postpartum ]floor

- Continue routine post[partum][operative] care

- Pain: []

- Follow up AM CBC

- Encourage ambulation when able