S: (name, age, race) (G#Pfpal), s/p LTCS 2° to (condition), POD#, c/o (if pain ChLoRIDE PP), nursing comments (pt. events during that shift), +/- sx (CP, SOB, LE swelling, calf tenderness, N/V/D), +/- breast tenderness, quantity of vaginal bleeding, voiding urine, flatus, ambulatory or not, BM, and tolerating fluids or regular diet. Breast or bottle-feeding baby, for contraception considering (birth control type).
O: objective - General survey, VS (Tm, HR, RR, BP), CVP, PCWP, I/O x 2 shifts (IVF, PO/UO (Foley to gravity)/UO last shift, NGT (to low wall suction), NGT (to low wall suction), vomit, stool. Drains - include type (JP), number (#1), & location (RUQ), fluid (serosanguinous or otherwise)
PE findings: Skin, HEENT, pertinent location: if abdomen - distended/non-distended, +/- BS, fundal height/consistency, soft/-, -/+ tender in area; lochia (color, consistency, odor), perineum (lac repair, MLE wound) abdominal incision (clean and dry, sutures intact, no DC; or Drsng: intact, dry, clean, no DC.
Thorax/Lungs: CTA-B, COR: RRR, S1, S2, - m, r, g,
Ext: -c,c,e, edema, Homan's si:
Neuro: MAE, sensation intact, strength 5/5
Meds-if on ABX day #, RhoGam, pain meds, iron, MVT, stool softeners, etc.
Labs:
A: assessment based on data above (s/p LTCS 2° to ?, POD#, stable, afebrile, progressing well)
P: plan - diagnostic, therapeutics, DC plans, pt. education (D/C Foley, strict I/O, clear, ambulate qid, meds)
Sign