G__ P___ ___ ___ ___ Blood Type:

#preg TermDelivery—PreTermDelivery--Abortions-- Rh:

Living Rubella
RPR
PPD/POD #____ HbsAg
Atb day____ Started on___/___ Continue for ____total days PPD
HIV
Pt's Doctor Clinic

Subj:
Complaints:

PPD: urinary prob: color of urine

POD: bowel movements______ cause of C/S:_______________________________________
Locia:
Breast feeding: breast tenderness
Birth control pills:
Circumcision:
Social work:
Father available:
Who will take care of baby:
Help around the house:

Pain:
walked:
HypoT: HA, fever,

Coagulapathy: SOB, CP, calf tenderness/thigh tenderness

Epidural back pain:

OBJ:
Vitals Tc_______ Tmax_______@_______ P______ RR_______ BP_______
Labs: (Current) (on Admission)

General: well nourished, well developed, AAOx3, mental status, signs of depression
Breasts: engorgement, tenderness, discharge
Resp: CTA bilat
Cardio: S1___ S2___ Rate and rhythm
Abdomen: Bowel sounds_____Soft____ non-distended____ tenderness________rebound tenderness_____
Uterus: firm/boggy________ Level compared to umbilicus______
Incision: Dressing off day#______, clean____Dry____Staples_____Sutures______ remove on_______
Genital: lochia_______
A/P
____y/o G_P_ _ _ _ s/p NSVD or C/S for ________

(1) Diet:
(2) Encourage ambulation—see Physical Therapy
(3) Discharge Planning: social work______
(4) see doctor ________ at 4-6wk at ____________________clinic
(5) Vaccine: Tetanus booster________Rubella vaccine____________RhoGam_______________
(6) Contraceptive
1. breast feeding → Micronor
2. not breast feeding--> any OCP/patch/ring
3. Depo-Provera (ok in breast feeding)
4. If IUD, what for next 2 mo?