I use the following postpartum note for uncomplicated vaginal deliveries. I simply copy and paste in TraceVue (our OB EHR) and then edit. If there are any complications, see here.
SUBJECTIVE:
Pt doing well. Pain is well controlled with meds. Afebrile. No chills.
Scant/normal lochia. Voiding. Up and walking.
Eating regular diet. No N/V. Passing gas. No BM yet.
Breastfeeding without difficulty.
No Complaints
OBJECTIVE:
VSS, Afebrile
Heart: RRR, No m/r/g. No thrills or heaves.
Lungs: CTAB
Abdomen: Firm fundus, at umbilicus. Soft abd NT. Normal BS.
Normal lochia
Extremities: No edema,cyanosis, clubbing
Hgb / HCT:
ASSESSMENT:
24-year-old G2P2 @ 37 weeks, PPD#1
Pt doing well. Afebrile. No chills. VSS. Tolerating diet.
Prenatal labs: WNL
Breastfeeding without difficulty
Birth control method: To be decided at 6wk f/u
Uncomplicated postpartum course.
PLAN:
Routine postpartum care.
D/C tomorrow to f/u in 4-6 wks.
Discharge Medications
Ibuprofen 600mg po q6h prn pain. Max of 3 doses / 24hr.