Delivery Note
On (delivery date, time) this (age, race) female under (epidural, pudendal, local, no) anesthesia delivered a viable (male, female) infant weighing (weight) with APGAR scores of (0-10) and (0-10) at 1 and 5 minutes. Delivery was via (SVD, LTCS, classical CS) to a sterile field. (Nuchal cord reduced.) Infant was (bulb, DeLee) suctioned at (perineum, delivery). Cord clamped and cut and infant handed to waiting (pediatrician, nurse). (Cord blood sent for analysis.) (Weight) (intact, fragmented, meconium stained) placenta with (2,3) vessel cord delivered (spontaneously, with manual extraction) at (time). (Amount) of (IV oxytocin, IM methylergonovine) given. (Uterus, cervix, vagina, rectum) explored and (midline episiotomy, nth degree laceration, uterus and abdominal incision) repaired in a normal fashion with (type) suture. EBL (amount). Patient taken to RR in stable condition. infant taken to NBN in stable condition. Dr. (name) attending.
Medical Notes:
Admit/Transfer Orders
Progress (SOAP) Note
Discharge Summary
Procedure Note
Discharge Summary
Off-Service Note
Pre-Operative Notes
Operative Note
Post-Operative Note
Death Note
Post-Partum Note
Delivery Note
Cardiology Progress Note and Consult
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