On (delivery date, time) this (age, race) female under (epidural, pudendal, local, no) anesthesia delivered a viable (male, female) infant weighing (weight) with APGAR scores of (0-10) and (0-10) at 1 and 5 minutes. Delivery was via (SVD, LTCS, classical CS) to a sterile field. (Nuchal cord reduced.) Infant was (bulb, DeLee) suctioned at (perineum, delivery). Cord clamped and cut and infant handed to waiting (pediatrician, nurse). (Cord blood sent for analysis.) (Weight) (intact, fragmented, meconium stained) placenta with (2,3) vessel cord delivered (spontaneously, with manual extraction) at (time). (Amount) of (IV oxytocin, IM methylergonovine) given. (Uterus, cervix, vagina, rectum) explored and (midline episiotomy, nth degree laceration, uterus and abdominal incision) repaired in a normal fashion with (type) suture. EBL (amount). Patient taken to RR in stable condition. infant taken to NBN in stable condition. Dr. (name) attending.
Progress (SOAP) Note
Cardiology Progress Note and Consult
Learn how to do an H&P correctly!
Look like a superstar physician!
Don't make rookie mistakes!
Outshine your cohorts!
Be able to bill better!
Make a case for a higher level of care!
The money is in the assessment and plan!