History and Physical Advice Tips Secrets

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Post Partum Note

S: patient comments or complaints, nursing comments, CHECK pain control, breast tenderness, quantity of vaginal bleeding, urination, flatus, bowel movement, lower extremity swelling, ambulation, breast or bottle feed, birth control type.

O: VITALS: blood pressure, pulse, respirations, temp.

INS/OUTS: IV fluid, PO intake, emesis, urine, stool.

EXAM: breath sounds, bowel sounds, fundal height/consistency, incision/episiotomy condition, lower extremity edema, Homan's sign.

MEDS: RhoGAM, pain med, iron, vitamins, stool softener.

LABS: CBC, Rd status.

A: assessments based on above data.

P: medication changes, lab tests, procedures, consults, discharge, etc.


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Medical Notes:
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Progress (SOAP) Note
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Discharge Summary
Off-Service Note
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Operative Note
Post-Operative Note
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Post-Partum Note
Delivery Note
Cardiology Progress Note and Consult

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