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.
Progress (SOAP) Note
Cardiology Progress Note and Consult
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