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MCH Note Templates

MCH Note Templates. Daniel Stulberg, MD UNM DFCM 10/5/2011. Delivery Note. Delivery Note for Vaginal Delivery Stage 1: _ yo G _ P _ at _ weeks EGA admitted for _. Patient progressed to complete in _ hours.

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MCH Note Templates

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  1. MCH Note Templates Daniel Stulberg, MD UNM DFCM 10/5/2011

  2. Delivery Note Delivery Note for Vaginal Delivery Stage 1: _ yo G _ P _ at _ weeks EGA admitted for _. Patient progressed to complete in _ hours. Stage II: Patient pushed for _ hours/minutes to deliver a viable, vigorous _male/_female infant at _ weighing _ gms and APGARS _/_ _over intact perineum. Shoulders delivered easily, cord clamped and cut. Baby _placed on maternal abdomen _ handed to RN _ handed to pediatric staff in attendance for _. Stage III: Placenta delivered spontaneously with gentle manual traction and active management of third stage. Placenta was intact to inspection and normal in appearance. Inspection revealed: _no lacerations of perineum or vagina _hemostatic second degree laceration _tear which was repaired with _ _ lap sponges were required, the patient was wanded showing no retained lap sponges and lap count correct Good hemostasis with fundal massage and 20 Units of pitocin in IV infusion. EBL _ cc. Instrument count correct. Mother and infant in stable condition.

  3. Newborn Interim Day Newborn Daily Progress Note ID: _weeks gestation, born_ via _ at DOL _, Apgars _. Subjective: Complains of _, feeding q _ hours, has voided and stooled Vitals: Active Inpt Meds: bupivacaine (bupivacaine pres-free 0.25%) 0.5 mL Infiltration ONCEsucrose 24% (Sweet-ease) 11 mL By Mouth ONCE Active IV Meds: None Active PRN Meds: petrolatum topical 1 application Topically AS DIRECTED Last 48 hr One Time Meds: (Completed) erythromycin ophthalmic (erythromycin ophthoint) 0.25 % Both Eyes once then discontinue(Completed) phytonadione (vitamin K1 inj Neo/Ped) 1 mg IntraMuscular once then discontinue(CONTINUED NEXT SLIDE)

  4. Vital Signs Recent (Ranges for last 30 hrs) Temperature: 37.2 (37.2 - 37.3) Heart Rate: 128 (128 - 142) Resp Rate: 48 (48 - 66) Dosing Weight: 3.1 kg as of 10/04/11 Height: 52.0 cm as of 10/04/11 Intake and Output Since 07:00AM As of 21:56Intake 0Output 0 0 mL UOPBalance 0 Previous 07:00AM-07:00AM Intake 0Output 1 1 mL UOP ( 0.0 cc/hr UOP)Balance -1 Fontanelle-soft, no bulging or retraction CV-RRR no m,r,g Pulm-CTA Bilaterally, no flaring or grunting noted Color-pink, well perfused, no discoloration Birth weight_ Follow up weight _ % weight loss _ Transcutaneous bilirubin _ LATCH score: _ No Lab Results Labs: A/P: Newborn infant doing well and meeting all milestones. Continue routine newborn care

  5. Newborn • Add Mother’s lab data if desired • “Lab perinatal maternity” stamp from the MOC • Group B Strep S  Negative for Gr 09/08/11 22:35 Hepatitis B Sur  Nonreactive     02/10/11 00:26 ABO Rh Type      B  POSITIVE     02/09/11 20:20 Antibody Screen  NEGATIVE        02/09/11 20:20 Rubella Immune   201.2 IU/ML     02/09/11 19:13 TreponemapalliNonreact        02/09/11 19:22 HCT               37 %            10/03/11 00:02 HCT               34 %            06/29/11 13:37

  6. Post Partum Day 1 Postpartum Note from Vaginal Delivery Subjective: Ambulating well, eating well, lochia less than menses, pain improving Prenatal care uncomplicated _complicated by: _ Objective: Vital Signs Recent (Ranges for last 30 hrs) Temperature: 36.9 (36.9 - 37.0) HtRt Monitored: 88 (88 - 95) SBP Cuff: 110 (99 - 120) DBP Cuff: 65 (54 - 65) MAP Cuff: 80 (69 - 82) Resp Rate: 18 (18 - 20) Dosing Weight: 80.0 kg as of 10/03/11 Height: 167.0 cm as of 10/04/11 Intake and Output Since 07:00AM As of 22:11Intake 0Output 0 No UO entered TodayBalance 0 Previous 07:00AM-07:00AM Intake 1Output 0 No UO entered Yesterday ()Balance 1

  7. Lungs: clear to auscultation Cardiac exam: regular rate and rhythm without murmur Abdomen: non-tender, uterus is firm at level of umbilicus Laceration/Episiotomy: None _Without swelling, erythema or discharge Legs: Non-tender Latch score if breastfeeding _ Group B Strep S Negative for Gr 09/13/11 23:19 Hepatitis B Sur Nonreactive 04/11/11 23:54 ABO Rh Type O POSITIVE 04/12/11 09:01 Antibody Screen NEGATIVE 04/12/11 09:01 Rubella Immune 329.7 IU/ML 04/11/11 22:16 Treponema palli Nonreact 04/11/11 22:25 HCT 30 % 10/04/11 08:38 HCT 37 % 10/03/11 02:15 Assessment: Patient is a _ year old G_ P _ Postpartum Day _ from a Vaginal delivery by maternal effort _vacuum assisted for _ who is meeting postpartum milestones. Pain control adequate. Social issues: _ Post partum Depression: _ Discharge Plan: Discharge today pending peds / Discharge in AM Rhogam if indicated Rubella immunization if indicated prior to discharge DTdap offered Contraception plan: Postpartum exam in 4-6 weeks at _ clinic

  8. Demo • Pushed out notes = is the prompt • Questions • Suggestions • Cautions • Only document what you actually did • Don’t copy out of date info

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