Sample SOAP Note for Obstetrics

S: no complaints, contractions/cramping, leaking fluid, HA, N/V, vision changes, CP, SOB, RUQ pain, leg swelling

O: Vitals

         Heart:                                                                           

         Lungs:

         Abd:

     FHT: 150s, mod var, reactive, no decels                              

     TOCO: 6 ctx/hr                                                                

         terbutaline bolus x4 yesterday                             

         terb pump 0.05

         nifedipine 20mg q 6

         indocin 10mg q4

         MgSO4 @ 2g/hr

      Labs: AST=45, ALT=38

                24hr urine protein

A/P: IUP @ 26 6/7 wks, triplets, cerclage, PTL       

1)       Consider increasing terb pump

2)       Rescan on Tues 1/16/02

3)       Tolerating Mg

4)       Repeat labs in 24hours

·      Topics to be familiar with:  PTL, normal labor, cervical incompetence, GDM, Preeclampsia, multiple gestation

·         Things to ask post-partum patients:

ü       Pain control, & what meds they’re on for it

ü       Lochia (heavy, moderate, light—how often are they changing their pad)

ü       Incision check if c-section, or how their “birth canal” is doing if vaginal delivery

ü       Breast or bottle feeding?

ü       Contraception?

ü       Circumcision?  (if male baby, of course)

ü       When does she think she’ll be ready to go home?

Abbreviations:  

AMA – advanced maternal age

AFR – amniotic fluid reduction

ART – assisted reproductive technology

IUGR – intrauterine growth restriction

IUFD – intrauterine fetal demise

IUI – intrauterine insemination

GDM – gestational diabetes mellitus

NSVD – normal spontaneous vaginal delivery

PLTCS – primary low transverse c-section

RLTCS – repeat low transverse c-section

TTTS – twin-twin transfusion syndrome

VBAC – vaginal delivery after cesarean