rev 5/1/2017
Summary: NSVD of a live male, 3000 gm and Apgars 9/9. Delivered LOA, no nuchal cord, light
meconium. Nose and mouth bulb suctioned at perineum; body delivered without difficulty. Cord
clamped and cut. Baby handed to nurse. Placenta delivered spontaneously, intact. Fundus firm, minimal
bleeding. Placenta appears intact with 3 vessel cord. Perineum and vagina inspected – small 2nd degree
perineal laceration repaired under local anesthesia with 2-0 and 3-0 vicryl suture in the usual fashion.
EBL 350cc. Hemostasis. Pt tolerated procedure well, recovering in LDR. Infant to WBN.
3. Sample Operation Note
Date and time:
Pre-op Diagnosis: Symptomatic uterine fibroids or Pregnancy at term, failure to progress
Postop Diagnosis: Same
Procedure: TAH/BSO or Cesarean Section
Surgeon (Attending):
Residents:
Anesthesia: GET (general endotracheal, others include spinal, LMA, IV sedation)
Complications: None
EBL: 300cc
Urine Output: 200 cc, clear at the end of procedure
Fluids: 2,500 cc crystalloid (include blood or blood products here)
Findings: Exam under anesthesia (EUA) and operative
Specimen: Cervix/uterus
Drains: If placed
Disposition: Recovery room, Surgical ICU, etc
4a. Sample Postpartum Notes (Soap format)
Date and time:
Subjective: Ask every patient about:
Breastfeeding – are they breastfeeding/planning to? How is it going? Baby able to latch on?
Contraceptive plan with relevant sexual history
Lochia (vaginal bleeding) – Clots? How many pads?
Pain – cramps/perineal pain/leg pain? Relief with medication? Do they need more pain meds?
Objective
Vital signs and note tachycardia, elevated or low BP, maximum and current temperature
Focused physical exam including
o Heart
o Lungs
o Breasts: engorged? Nipple – skin intact?
o Abd: Soft? Location of the uterine fundus – below umbilicus? Firm? Tender?
o Perineum: Assess lochia (blood on pad, how old is pad?)
o Visually inspect perineum – Hematoma? Edema? Sutures intact?
o Extremities: Edema? Cords? Tender?
Postpartum labs: Hemoglobin or hematocrit
Assessment/Plan: PPD#_S/P NSVD or Vacuum or Forceps (with 4
th
-degree laceration, with pre-
eclampsia s/p Magnesium Sulfate)
General assessment – Afebrile, doing well, tolerating diet