Maternity Progress Note

Complete Note, Objective/Exam Elements
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[textarea rows=25 columns=80 default="SUBJECTIVE:
Postpartum day *** s/p NSVD/C-section. Lochia decreasing and does not appear to be infected. Patient is ambulating and urinating without difficulty. No leg/calf pain or swelling and no shortness of breath
OBJECTIVE:
General: Well developed, well nourished female in no acute distress. Vitals noted and stable.
Lungs: Clear to auscultation bilaterally
Cardiac: S1/S2, no S3/S4, no murmurs. Rhythm is regular
Abdomen: Soft, nontender. Uterine fundus is firm and below the umbilicus. ***Incision appears well healed without evidence of infection***
Extremities: Warm and well perfused. No clubbing, cyanosis or palpable cords
ASSESSMENT/PLAN:
#1 s/p ***NSVD/C-section***
Doing well. Analgesia adequate. Continue to encourage ambulation. Monitor for signs and symptoms of chorioamnionitis."]

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