OBGYN Post-Op Note (Blank Template)

OBGYN Post-Op Note

 Pre-op diagnosis: ___ yo G#P#### @ # weeks – # days PPROM, induction of labor with ___

Post-op diagnosis: same, delivered, liveborn M/F infant

Procedure: i.e. cesarean section

Surgeon/assistant:

Type of anesthesia:

IV fluids: 

Estimated blood loss: 

Urinary output: 

Drains (exact location): JP

Pathology: 

Findings:(C-section)

  • liveborn (SEX)  at ___am/pm   from vtx/breech position.
  • Apgar’s ___/___ Wt. ___
  • Cord blood sent to lab
  • Placenta intact with 3VC
  • Clear/meconium fluid
  • Nl tubes,ovaries, uterus

Complications: no complications

Disposition: tolerated well. stable condition transferred to recov. rm

 

Mr. Stepwards, MS3

DATE

Pager: XXXX