Rotation Information |
Administration |
Rotation Information |
Administration |
Curriculum Goals |
Reference Articles |
L&D Protocols |
Pre-Test |
|
Lectures |
FHT Tutorial |
(by regulations at MaineGeneral, differs by institution)
| Admit Note | Progress Note | Delivery Note | Post-partum Note |
Admit Note (written only, not dicated)
Admission History –
Pt is a ___ year old G__, P___ LMP ____ and EDD ___, currently at 35 2/7. She is a patient of ___ Pregnancy complicated by _____________. She comes in with (contractions every 5 minutes, membranes intact/ruptured – when, clear vs. meconium, last exam at recent visit at office)
Prenatal Data
Blood type (when Rhogam given if Rh-), Hbg/Hct, Rubella status, RPR, Pap, GC, Chlamydia
Ultrasound if any, reasons, dates, results
AFP results and GTT results
GBS results
Weight gain
Mother planning to Bottle or Breast Feed
? Circumcision if boy
Presented at ___ weeks to Dr. __ for prenatal care
OB History
___ Year, __SVD vs C/S, Length of labor, baby’s sex and weight
Complications
History of Tab. Vs. Sab – what year, how far along
Past Medical History
Meds
Allergies
Family and Social History (illnesses of 1st degree relatives and work, substances, exercise)
ROS – especially HA’s, visual changes, abdominal pain/RUQ pain, leg pain, swelling, dysuria, bleeding
Physical Exam
HEENT
Breasts
Heart/Lungs
Abdomen – Estimated fetal weight by leopolds
Vaginal exam – cervical dilation/effacement/station, cervix position, presenting part, membranes
Ext
DTR’s
Fetal Heart Rate on monitor/Uterine contractions on monitor
Assessment –This should include an assessment of the woman and of the fetus
Ex – a G2P1 at term in active labor, reassuring fetal heart tones.
Plan - **include notification of attending or covering attending**
Progress Note -
There should be a progress note on the chart anytime something significant happens (pt asks for pain meds and is checked, gets into tub and is checked, AROM is performed, or every two hours for a normal labor even if no vaginal exam). Each progress note should address mother and fetus.
Date/Time
S- mother requesting pain medications
O- contractions palpate strong, contractions irregular q2-6
FHT – 130’s with good variability, accels up to 150’s, no decels
SVE – 4cm/100%, 0 station, vertex, membrane intact
A - G2P1 @term, active labor, reassuring fetal heart tones
P- Stadol 1mg IV
(Dictation type 45 – also write a brief version in the chart)
___ is a __ year old G__, P__ patient of ___ with a LMP of ___, EDD of __ based on ___ and/or U/S of ___. Her antenatal course was complicated by ____. She presented to L&D at (time), on (date). Describe fluid, membranes, contractions, cervical exam and strep status.
Stage I : Duration and Times
Fetal Heart monitoring, IUP/amnio infusion, Progression of labor, AROM with description, Analgesia, antibiotics
Stage II: Duration and Times
Patient effort, Anesthesia (if any) episiotomy and/or lacs, baby sex, weight, Apgars, unusual findings, presence of attendants, description of cord.
Stage III: Duration and Times
Spontaneous vs. manual delivery of the placenta, description of placenta, meds
Description of placenta, meds, description of repair or episiotomy and lacs, use of packing sponges and their removal. EBL.
Total Labor time
Patient’s condition on transfer to floor
In attendance:
Post-Partum (or Post Op) Progress Notes
Post partum day (#)
S – diet, activity, pain, voiding, flatus or bowel movements, breast feeding?, mothering and bonding
O – vitals, breasts, lungs, fundal size and tenderness, lochia, perineum/hemorrhoids, extremities, labs
A –PPD #1, NSVD, breast feeding well
P – rubella or varicella vaccine?, iron? breast feeding consultant, routine postpartum care & teaching, contraception, anticipated d/c date, follow-up plans.