OBGyn Patient Name Page 1 of 2 MR

OB/Gyn Patient Name Page 1 of 2 MR Number DOB Date Time Labor and Delivery (every 2 hours) Progress Note—MSIII S: 24 hour events… Pt. Subjective assessment of contractions, abd. pain, changes in vision, discharge, bleeding, SOB, leg pain, edema. O: Vitals: Tmax / Tcurrent / bp / hr / resp / O 2 sats /accucheck I/O: last 8 hr- ‘in” (PO, IV)/ “outs” (urine, stool) last 24 hr- ‘in” (PO, IV)/ “outs” (urine, stool) Labs: Meds: (including Mag, pitocin) Fetal montior: ctx/ fetal hr/ variability/ accel. , decel. Exam: GEN: HEENT: CV: PULM: ABD: EXT: NEURO: STERILE VAGINAL EXAM: STERILE SPECULUM EXAM: A/P: ______ y/o G__P__ female at ____weeks, ___/7 days gestation with PMHx of _______ now ____. List problems and plan to treat each. Op Note: • Look in your pocket. There should be a Maxwell’s in there. Follow the format given to you. Things to Know: • OB is a taxing, but rewarding rotation. • Be sure to ask for opportunities to catch babies and do surgical procedures—there should be ample opportunity. • You will be tired from being on call… make the most of your time at the hospital. • Proper OR etiquette applies to OB as well. Scrub up and retract that bladder! • PATs are pre-op physical exams performed in the Surgical Admitting Center: be thorough and quick. • Practice your knots so you can be a star when you get suture something. • Always carry an energy bar or food in your lab coat pocket • Pee BEFORE going to the OR. It is bad form to scrub out routinely for bathroom breaks.

OB/Gyn Page 2 of 2 Patient Name MR Number DOB Date Time Post-partum Progress Note—MSIII S: 24 hour events… Pt. Subjective assessment of N/V/F/C, pain, wound, discharge, SOB, leg pain, bowel activity. (It will be similar to a surgery note). O: Vitals: Tmax / Tcurrent / bp / hr / resp / O 2 sats /accucheck I/O: last 8 hr- ‘in” (PO, IV)/ “outs” (urine, stool) last 24 hr- ‘in” (PO, IV)/ “outs” (urine, stool) Labs: Meds: Exam: GEN: HEENT: CV: PULM: ABD: EXT: NEURO: GU: WOUND: A/P: ______ y/o G__P__ female with PMHx of _______ now with ____ s/p _____ (NSVD, forceps/vaccuum-assist. , C/S ), postpartum day ____. List problems and plan to treat each. Books: • Beckmann’s Obstetrics and Gynecology (covers everything on the test – read this book once!) • Maxwell’s Essentials in Obstetrics and Gynecology (“required” but not the best for test prep) • Blueprits in OB Gyn (for review only) • Essentials of Obstetrics and Gynecology by Hacker and Moore (better comprehensive book) • First Aid for the OB/Gyn Clerkship • Netter’s Obstetrics, Gynecology, and Women’s Health (great for visual learners) Patient Name MR Number DOB SOAP Note—Gyn/Onc Service Date This is essentially a surgical service. Thus, the surgery format for SOAP Complete these notes before rounds. note should be used. Time This is essentially a surgical service. Thus, the surgery format for SOAP note should be used. Op Note: Look in your pocket. There should be a Maxwell’s n there. Follow Look in your pocket. There should be a Maxwell’s in there. Follow the format given to you.