Family Medicine Residency Program

Resident Survival Page

Sample OB Notes

Labor Note

Example 1

Date/ Time

S: Complains of more pain, wants relief

O: Cervix 5 cm dilated, completely effaced, 0 station

Membranes Intact, Bag of Water bulging

External Fetal Monitor shows Contractions (comment on Frequency), fetal strip reactive with good short and long-term variability on external tracing, baseline 150

A: Active phase labor with satisfactory progress

P: Expectant management

If Epidural desired then comment on notification of Anesthesia

Address Pain control with Demerol Cocktail or Fentanyl

Attending OB notified. 

Sign Note

PGY III

Example 2

Date / time

S: C/O gush of fluid

O: Cervix 8 cm/C/+1

Membranes grossly ruptured. Nitrazine positive.

EFM: Baseline 150, no decels, Contractions Q 5min.

Fetal strip Good long-term variability baseline 150

A: SROM

Active Phase labor with good progress

P: OB attending notified

Sign your Note

PGY I

Example 3

Time/Date

S: C/O rectal pressure

Still comfortable with CLE

O: Cervix C/C/+4 (head visible with separation of labia)

EFM: Unchanged except for mild variable decels with each contraction

A: 2nd Stage Labor

P: Begin pushing

OB attending here

Sign Note

PGY II

Delivery Note

Time/ Date

Diagnosis: Term pregnancy, Spontaneous Labor (comment on Vacuum assist if done)

Procedure: Normal Spontaneous Vaginal Delivery

Attending: Dr. Brock

Assistant: Dr. Hubli

Anesthesia: Epidural

Meconium: if present comment on suction at perineum

Infant: Female, 7lbs 4 ounces, at 1307 on 1/3/2003. Apgars 9/9

Nuchal cord: present/absent

Placenta: Spontaneous, 3-vessel cord

Episiotomy: None

Laceration: Present / Absent (if present comment on Repair)

Uterus: Not explored

Complications: none

EBL: Average (~300 cc)

Baby to Newborn Nursery Or ICN (if ICN comment on the reason)

Blood type: A+

Rubella: Immune

Sign Note

Post Partum Note

Time/date
PPD#1

S/P NSVD, Female, 2° perineal laceration, Breast-feeding.

Feels generally well, but tired. No medical complaints. Voiding well. Baby doing well

VS T=98.1, (Tmax=99.2), P=102, R=18, BP=100/65

Breasts soft, NT

Abdomen: Uterus firm, at Umbilicus, non-tender. Bowel sounds present.

Calves: no tenderness

Lochia: Moderate, non-foul

Perineum: Intact

Labs: CBC pending from this AM, Rubella status, PPD status, Rh of the mom

A/P: Stable PPD#1

Encourage Breast-feeding

Discussed contraception. Prefers OC’s. Non-smoker.

Rx for Triphasic28s (3 packs) written

Sign Note

D/W attending

PPD#2

Date/time

S/P NSVD, Female, 2° perineal laceration., Breast-feeding.

Feels fine, no C/O

VS: Normal. A febrile.

Breasts soft, NT

Abdomen: Uterus firm, at Umbilicus, NT.

Calves: no tenderness

Lochia: non-foul

Perineum: Intact

Labs: CBC yesterday:

A/P: Stable PPD#2

Home today per Attending

Routine PP instructions given

Begin OCPs in 2 weeks

F/U visit in 6 weeks

Rx: PNVs One PO Daily

If Hct less then 30

then d/c home on Iron sulfate for a month w 2 refill

FeSo4 325 mg PO TID #150
Triphasic 28s One PO QD #3 Packs

Brief Operation Note Template

Date/ Time:
Preop diagnosis: reason for surgery
Postop diagnosis: actual finding at surgery
Procedure: performed
Anesthesia: type; i.e., general, spinal, epidural, etc
Surgeon: attending physician
Assistant(s): resident/medical student
Estimated Blood Loss:
IV Fluids:
Urine output:
Findings: in detail what was found at surgery, describe sizes, Adhesions, etc
Pathology: what was sent to the pathologist for evaluation
Disposition: where patient is going from operating room.

Sign Note. 

Post Operative Note Template

Time/date

POD#

S: how patient is feeling, pain control, diet, ambulating, any complaints
Lochia, passing flatus / bowel moment.

O: VS T=98.1, (Tmax=99.2), P=102, R=18, BP=100/65

General appearance
Chest/CV
Abdomen—incision-clean/dry/intact, assess bowel sounds? Tenderness- describe where
Extremities—edema29 year old,

A/P: POD#__ s/p__________________
pain controlled, consider d/c PCA, change to oral meds
D/C Foley, advance diet with flatus, encourage ambulation, etc.

Sign Note

D/w Attending 

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