Maternity Admission Note

Complete Note, Obstetrics
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[textarea default="HISTORY OF PRESENT ILLNESS:&#13;&#10;***year old G*** P*** at ***weeks*** estimated gestational age by ***18-20 week ultrasound/early ultrasound/LMP*** presenting to Labor and Delivery for ***spontaneous onset of labor/spontaneous rupture of membranes/induction of labor/observation***. She reports continued fetal movement and no vaginal bleeding.&#13;&#10;Prenatal labs: ***blood type***, antibody screen ***negative/positive/unknown***, Syphilis ***IgG negative/RPR non-reactive/Syphilis IgG positive/Syphilis unknown***, Hepatitis B Virus Screening ***HBV S Ag Negative/HBV S Ag Positive/HBV S Ab Positive/HBV Unknown***, HIV ***Unknown/Negative/Positive***, Rubella ***Immune/Equivocal/Not Immune/Unknown***, GBS ***negative/positive/unknown***, Glucose tolerance testing: ***1 hr GTT, passed/1 hr GTT, failed/3 hr GTT, passed/3 hr GTT, failed***, ***Normal 18-20 week ultrasound/Abnormal ultrasound***.&#13;&#10;Pregnancy complications: ***Uncomplicated/GBS positive/GBS Unknown/Hepatitis B surface antigen positive/< 37 weeks gestation/PIH/Pre-eclampsia/Diabetes/Gestational diabetes/Multiple gestation/Breech presentation***&#13;&#10;REVIEW OF SYSTEMS: All systems reviewed and negative except as noted per History of Present Illness"]
[textarea default="Exam:&#13;&#10;General: Well developed, well nourished gravid female in no acute distress. Vitals noted and stable.&#13;&#10;Lungs: Clear to auscultation bilaterally&#13;&#10;Cardiac: S1/S2, no S3/S4, no murmurs. Rhythm is regular&#13;&#10;Abdomen: Gravid, soft, nontender. FM palpable&#13;&#10;Extremities: Warm and well perfused. No clubbing, cyanosis or palpable cords&#13;&#10;Pelvic: Normal external female genitalia. Cervix is ***.&#13;&#10;EFW: ***&#13;&#10;Fetus is *** presentation by leopold's and bedside ultrasound"]
[textarea default="#1 ***Active Labor/Induction of Labor/Premature rupture of membranes***&#13;&#10;-Admit to labor and delivery for management of labor&#13;&#10;-Begin augmentation with Pitocin&#13;&#10;-Begin cervical ripening with cytotec&#13;&#10;-Begin antibiotic prophylaxis for GBS positive status with Penicillin&#13;&#10;-Begin antibiotic prophylaxis for GBS positive status with Gentamycin"]
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posted by: Mark Morgan, M.D.
post/review dates: April 1, 2010; September 4, 2015
revision history: <a href="https://github.com/soapnote/SOAPnote-site/tree/master/generator/txt/pregnancy/maternity-admission-note.txt" target="_blank">www.github.com/soapnote/SOAPnote-site/tree/master/generator/txt/pregnancy/maternity-admission-note.txt</a>
markup link: <a href="../../generator/txt/pregnancy/maternity-admission-note.txt" target="_blank">www.soapnote.org/generator/txt/pregnancy/maternity-admission-note.txt</a>[/html][/conditional]



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