Post Partum Note

Patient comments or complaints, nursing comments. Check pain control, breast tenderness, the quantity of vaginal bleeding, urination, flatus, bowel movement, lower extremity swelling, ambulation, whether she is breast or bottle feeding, and the type of birth control planned.

Vitals: blood pressure, pulse, respirations, temperature.

Ins and outs: IV fluid, oral intake, emesis, urine, stool.

Exam: breath sounds, bowel sounds, fundal height and consistency, condition of the incision or episiotomy, lower extremity edema, Homan's sign.

Meds: RhoGAM, pain medication, iron, vitamins, stool softener.

Labs: CBC, Rh status.

Assessments based on the data above.

Medication changes, lab tests, procedures, consults, discharge planning.