To divide er follow-ups, referrals and new patient requests more evenly and to allow more access for patients, please indicate the topics you would be willing to take on or perform an initial workup:

Progress Note and Discharge Note Examples
OB LABOR NOTE

S: Comfortable with epidural” or “Breathing through contractions.”
O:
1. Vitals. 2. Most recent SVE (sterile vaginal exam) performed by (RN, MD, resident) 3. Fetal tracing: baseline 140, moderate variability, accelerations, no decelerations 4. Tocometer : contractions every 4 min A/P: SIUP at 39w1d, active labor, undergoing Pitocin augmentation, GBS + 1. Continue augmentation (or induction) with Pitocin (or cytotec, cervidil, etc) 2. Fetal tracing reassuring 3. Anticipate vaginal delivery 4. Continue GBS antibiotic prophylaxis
POSTPARTUM NOTE—VAGINAL DELIVERY

S: Normal lochia. Voiding without difficulty. Working with lactation consultant on latch.
Colostrum coming in well. Minimal discomfort from vaginal laceration
O: Vitals
Gen
Heart
Lungs
Fundus firm, nontender, 2 cm below umbilicus
LE: 1+ edema, no calf tenderness to palpation, negative Homan sign
Labs:
Recent CBC
A/P:
G1P1 Postpartum Day #1 from spontaneous delivery complicated by shoulder dystocia,
now with postpartum anemia
1. Routine postpartum care. 2. Lactation consultation ordered. 3. Iron supplementation. 4. Anticipate discharge home tomorrow. POSTPARTUM NOTE—CESAREAN DELIVERY

S: Minimal lochia. Foley still in place. Bottle feeding. Pain well controlled with oral pain
meds and Toradol. No flatus yet. Tolerating clear liquids.
O: Vitals
Gen
Heart
Lungs
Abdomen (bowel sounds, guarding or rebound, distension)
Fundus firm 2 cm below the umbilicus, mildly tender consistent with POD #1
Bandage clean and dry OR Incision intact (with staples or steristrips), no erythema,
ecchymosis or active drainage
LE exam
Labs:
Post op CBC
A/P:
G3P2 POD #1 from low transverse cesarean delivery
1. Routine postop care. 2. Lactation consultation ordered. 3. Foley out today. 4. Switch to oral pain meds. 5. Milk of magnesia to move bowels. 6. Anticipate discharge home tomorrow.
POST OP GYN SURGERY NOTE

S: Pain well controlled on morphine PCA. No nausea. Tolerating regular diet. Passing
flatus. Voiding well after foley removed.
O: Vitals
Gen
Heart
Lungs
Abdomen (bowel sounds, guarding or rebound, distension)
Bandage clean and dry OR Incision intact (with staples or steristrips), no erythema,
ecchymosis or active drainage
LE exam
Labs:
Pathology:
A/P:
58 yo G4P4 POD #3 from total laparoscopic hysterectomy and BSO, doing well.
1. Routine postop care. 2. Prescriptions written and wound care instructions reviewed. 3. Hormone replacement after ovarian removal: none needed 4. Anticipate discharge home today. DISCHARGE INSTRUCTIONS
1. Home 2. Diet: ADA (American Diabetic Associate) diet if diabetic 3. Activity: stairs, showers, baths, intercourse, douches, tampons walking, high- 4. Follow-up appointment(s): Mother and Baby 5. Medications: Pain, Antibiotic, Hormones 6. Wound care: Staples, Drains, Suture removal, OK to get wet or take soaking 7. Call immediately if: fever, chills, vomiting, vaginal bleeding over 2 soaked pads

Source: http://alaskadigitalvisions.com/wwami/Documents/Progress_Discharge_notes.pdf