rev 5/1/2017
SAMPLE NOTES/COMMON ABBREVIATIONS
Tools for the OB/GYN clerkship, contained in this document:
1. Sample obstetrics admission note
2. Sample delivery note
3. Sample operative note
4. Sample postpartum note
a. Vaginal delivery
b. Cesarean section orders/note
5. Sample gynecologic history & physical (H & P)
6. Sample labor rounding note
7. Admission orders
8. Commonly-used abbreviations
9. Spanish lesson
rev 5/1/2017
1. Sample Admission to Labor and Delivery Note
Date & time
Identification (includes age, gravidity, parity, estimated gestational age, and reason for admission):
26yoG3P1A1 @ 38W5D EGA presents with painful contractions since noon. Pt reports good fetal
movement, and denies rupture of membranes or vaginal bleeding.
LMP:
Estimated date of confinement (EDC):
Chief complaint:
History of present illness (includes Prenatal Care (PNC): Labs, including HIV, GBS, GDM/HTN, # PNC
visits, wt gain, s=d, etc.
Past History:
Obstetrics:
List each pregnancy (NSVD, st 4000 grams, complicated by gestational diabetes and
shoulder dystocia)
Gynecology:
PMH and PSH:
Medications: PNV, FeSO4
Allergies: No Known Drug Allergies (NKDA)
Social History: Ask about Tobacco/EtOH/Drugs
Physical exam (focused):
General and Vital signs
Lungs
CV – (Many pregnant women have a grade 1-2/6 systolic ejection murmur
Abd – Gravid, fundus mom-tender (NT), fundal height (FH) 38 cm, Leopold maneuvers:
Fetus is vertex (VTX), estimated fetal weight (EFW) 3300 gm
Sterile speculum examination if indicated to rule out spontaneous rupture of membranes
(SROM)
Sterile vaginal exam (SVE) = 4 cm/80%/VTX/-1 as per Dr. Smith/time
Ext – No Cyanosis, clubbing or edema (C/C/E), NT
Pertinent Labs:
Ultrasound: Date: 10 wks by crown-rump length (CRL)
Date: 20 wks, no anomalies
Assessment: 26yo G3P1 at term, in labor fetal heart rate tracing (FHRT) reassuring
Intrauterine pregnancy (IUP) at 30 weeks gestation
FHRT – Baseline 140’s, accelerations present, no decelerations
Contractions – q 4-5 min
Any pertinent past medical or surgical history
Plan: Admit to L & D
NPO except ice chips
IV – D5LR at 125 cc/hr
Continuous electronic fetal monitoring CBC, T & S, RPR
Anticipate NSVD
2. Sample Delivery Notes
Date and time:
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Summary: NSVD of a live male, 3000 gm and Apgars 9/9. Delivered LOA, no nuchal cord, light
meconium. Nose and mouth bulb suctioned at perineum; body delivered without difficulty. Cord
clamped and cut. Baby handed to nurse. Placenta delivered spontaneously, intact. Fundus firm, minimal
bleeding. Placenta appears intact with 3 vessel cord. Perineum and vagina inspected – small 2nd degree
perineal laceration repaired under local anesthesia with 2-0 and 3-0 vicryl suture in the usual fashion.
EBL 350cc. Hemostasis. Pt tolerated procedure well, recovering in LDR. Infant to WBN.
3. Sample Operation Note
Date and time:
Pre-op Diagnosis: Symptomatic uterine fibroids or Pregnancy at term, failure to progress
Postop Diagnosis: Same
Procedure: TAH/BSO or Cesarean Section
Surgeon (Attending):
Residents:
Anesthesia: GET (general endotracheal, others include spinal, LMA, IV sedation)
Complications: None
EBL: 300cc
Urine Output: 200 cc, clear at the end of procedure
Fluids: 2,500 cc crystalloid (include blood or blood products here)
Findings: Exam under anesthesia (EUA) and operative
Specimen: Cervix/uterus
Drains: If placed
Disposition: Recovery room, Surgical ICU, etc
4a. Sample Postpartum Notes (Soap format)
Date and time:
Subjective: Ask every patient about:
Breastfeeding – are they breastfeeding/planning to? How is it going? Baby able to latch on?
Contraceptive plan with relevant sexual history
Lochia (vaginal bleeding) – Clots? How many pads?
Pain – cramps/perineal pain/leg pain? Relief with medication? Do they need more pain meds?
Objective
Vital signs and note tachycardia, elevated or low BP, maximum and current temperature
Focused physical exam including
o Heart
o Lungs
o Breasts: engorged? Nipple – skin intact?
o Abd: Soft? Location of the uterine fundus – below umbilicus? Firm? Tender?
o Perineum: Assess lochia (blood on pad, how old is pad?)
o Visually inspect perineum – Hematoma? Edema? Sutures intact?
o Extremities: Edema? Cords? Tender?
Postpartum labs: Hemoglobin or hematocrit
Assessment/Plan: PPD#_S/P NSVD or Vacuum or Forceps (with 4
th
-degree laceration, with pre-
eclampsia s/p Magnesium Sulfate)
General assessment – Afebrile, doing well, tolerating diet
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Contraception plans (must discuss before patient goes home)
Vaccines – does pt need rubella vaccine prior to discharge?
Breastfeeding? Problems? Encourage.
Rhogam, if Rh-negative
Discharge and follow-up plan
Patients usually go home if uncomplicated 24-48 hours postpartum
Follow-up appointment scheduled in 2-6 weeks postpartum
4b. Sample Postoperative Cesarean Section Orders/Note
Admit to Recovery Room, then postpartum floor
Diagnosis: Status post (S/p) C/S for failure to progress (FTP)
Condition: Stable
Vitals: Routine, q shift
Allergies: None
Activity: Ambulate with assistance this PM, then up and lib
Nursing: Strict input and output (I&O), Foley to catheter drainage, call MD for Temp > 38.4, pulse > 110,
BP < 90/60 or > 140/90, encourage breastfeeding, pad count, dressing checks, and Ted’s leg
stockings until ambulating
Diet: Regular as tolerated; some hospitals only allow ice chips or clear liquids
IV: Lactated ringers (LR) or D6LR at 125 cc/hr, with 20 units of Pitocin x 1-2 Liters
Labs: CBC in AM
Medications:
Morphine sulfate PCA (patient controlled analgesia) per protocol (1 mg per dose with 10 minute
lockout, not to exceed 20 mg/4 hours)
Percocet 102 tabs PO q 4-6 hours prn pain, when tolerating PO well
Vistaril 25 mg IM or PO q 6 hours prn nausea
Ibuprofen 800 mg PO q 8 hours prn pain, when tolerating PO well
Prophylactic antibiotics if indicated
Thromboprohylaxis for high-risk patients
Rhogam, if Rh-negative
Sample C/S Note
Date and Time:
Day #1 (Post-op day POD#1)
Subjective: Ask patient about:
Pain – relieved with medication?
Nausea/vomiting
Passing flatus (rare this early post-op)
Objectives
Vital signs and note tachycardia, elevated or low BP, maximum and current temperature
Input and output
Focused physical exam including
o Heart
o Lungs
o Breast: engorged? Nipples – Is skin intact?
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o Incision: Clean and dry, intact?
o Abd: Soft? Location of the uterine fundus – below umbilicus? Firm? Tender?
o Perineum: Assess lochia (blood on pad, how old is pad?)Visually inspect perineum –
Hematoma? Edema? Sutures intact?
o Extremities: Edema? Cords? Tender?
Postpartum labs: Hemoglobin or hematocrit
Assessment/Plan: POD#1 status post (S/P) C/S or repeat C/S (indication for the C/S)
Afebrile, tolerating pain with medication, oral intake, adequate urine output (>30cc/hr)
Routine post0op care
o Discharge Foley
o Discharge PCA or IV pain medications and PO pain Meds when tolerating PO
o Out of bed (OOB)
o Advance diet as tolerated
o Discharge IV when tolerating PO
Check hematocrit or CBC
5. Sample Gynecologic History and Physical
Introduction: Name, age, gravidity, parity and presenting problem
HPI:
Past Medical History/Past Surgical History:
Past Gynecologic History:
Menses – menarche, cycle duration, length, heaviness, intermenstrual bleeding, dysmenorrhea,
and menopause (if relevant).
Abnormal Pap smears, including time of last Pap
Sexually transmitted infections
Sexual history
Postmenopausal women. Ask about hypoestrogenic symptoms, such as hot flashes or night
sweats, vaginal dryness, and about current and past use of hormone/estrogen replacement
therapy.
Mammogram
Past OB History: Date of delivery, gestational age, type of delivery, sex, birth weight and any
complications
Family History:
Allergies:
Medication:
Social History:
Physical Exam: Complete
Review of Systems:
Plan:
1. Pap smear
2. Endometrial biopsy obtained
3. Medications, etc.
Two Samples Gyn Clinic SOAP Notes
S. 22 y/o G2P2 here for annual exam. Regular menses q 28 days with no intermenstrual bleeding.
IUD for contraception since birth of last child 2 years ago. NO problems with method. Minimal
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dysmenorrhea. Mutually monogamous relationship x 6 years. No hx of abnormal Paps. + BSE, jogs
twice a week, no smoking, no abuse, + seat belts.
O. Breasts: No masses, adenopathy, skin changes
Abd: No masses, soft, NT
Pelvic:
Ext genitalia: Normal
Vagina: Pink, moist, well rugated
Cervix: multiparous, no lesions
Bimanual: uterus small, anteverted, NT, no adnexal masses or tenderness
A. Normal exam
B. P. Pap, RTC1 year
* * * * *
S. 33 y/o with LMP 1 week ago here for follow up of chronic left sided pelvic pain. Patient first seen 6
months ago with complaints of pain x 2 years. She describes pain as dull and aching, intermittent, with
no relationship to eating but increased before and during menses. Pain has gotten worse over the last 6
months and requires her to miss work 2-3 days per month. No relief with NSAIDs. Patient has history of
chlamydia 5 years ago for which she was treated. No history of PID. Three partners within the past
year: no condom use No GI symptoms: regular BMs, no constipation, diarrhea, nausea or vomiting.
Past history of ectopic x 2 with removal of part of the left and right tubes. Also had rupture
appendectomy at age 20. On birth control pills for contraception.
O. Abdomen: 1+ LLQ tenderness, no peritoneal signs
Pelvic: Ext genitalia: Normal
Vagina: no discharge
Cervix: no lesions
Biman: uterus small, retroverted, NT, 3+ left adnexal tenderness, no right adnexal
tenderness, no masses palpated
A. Pelvic pain unresponsive to medical management; rule out endometriosis vs adhesive disease vs
chronic PID vs other
P. Schedule diagnostic laparoscopy
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6. Template for Intrapartum (L & D) Rounding Note
Pt Initials:
Room:
S: Pt feels/does not feel CTX. Has/plans epidural/pain controlled with _______ (epidural/IV Fentanyl)
Aware of /not aware of pressure sensation (if in active or second stage). Last void @ ____/has Foley.
?VB ?LOF
O: Vitals:
B/P range:
P:
T:
@
(time)
I/Os:
[If relevant, eg. On Magnesium, long labor]
Heart
Lungs
[Not needed every note]
Abdomen: soft between CTX/CTX palpate
(mild/mod/strong)/NT or T fundus.
EFW:
[Not needed every note]
Extremities:
Edema
Reflexes
+/- clonus
TOCO:
CTX q
min
FHT:
baseline
variability
(absent/mild/mod/marked)
decels (no/early/variable/late)
SVE:
Cm dilation/
%
effaced/
(-3 to +3) station
Admission Hgb
[Not needed every note]
Pertinent Labs:
(eg if pre-eclampsia serial labs)
A: Pt is a
Yo G
P
With: (eg in labor/induction of labor for _____)
Pregnancy c/b
(eg HTN/oligohydramnios/GDM/IUGR)
P:
1. Expectant management
- or ? intervention (eg Pitocin augmentation/AROM with next exam/place internal monitors)
-
2. GBS status
(+/- on ampicillin or penicillin)
3. RH
(pos/neg/ s/p Rhogam @
wks)
Rubella
(immune/Nomimmune
4. Feeding plans:
(breast or bottle)
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7. Admission Order
These vary a little from case to case, but the following are fairly general (format is ADC VAN DISMAL):
Admit: To the specific service or team
Diagnosis : List the diagnosis and the names of any associated surgeries or procedures
Condition: Such as Stable vs Fair vs Guarded
Vitals: Frequency
Activity: Ambulation, showering
Nursing: Foley catheter management parameters
Prophylaxis for deep venous thrombosis
Incentive spirometry protocols
Call orders Vital sign parameters for notifying the team
Urine output parameters
Diet: Oral intake management
IVF: Rates are typically set at 125 cc per hour
Special: Drain management
Oxygen management
Meds: Pain medications
Prophylactic orders, such as for sleep or nausea
The patients’ regular medications
Allergies:
Labs: Typically includes hemoglobin/hematocrit
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8. Commonly-Used Abbreviations
AB
abortion
MAB
missed abortion
SAB
spontaneous abortion
TAB
therapeutic abortion
EAB
elective abortion
ACOG
American College of Obstetricians and Gynecologists
AFP
Alpha Fetoprotein
MSAFP
Maternal serum alpha-fetoprotein
AGUS
Atypical glandular cells of unknown significance
AMA
Advanced maternal age
AFI
Amniotic fluid index
APGO
Association of Professors of Gynecology & Obstetrics
AROM
Artificial rupture of membranes
ASCUS
Atypical squamous cells of unknown significance
BBOW
Bulging bag of water
BBT
Basal body temperature
BMD
Bone mineral density
BPD
Biparietal diameter
BPP
Biophysical profile
BSO
Bilateral salpingo-oophorectomy
BTBV
Beat-to-beat variability
BTL
Bilateral tubal ligation
CIN
Cervical intraepithelial neoplasia
CPD
Cephalopelvic disproportion
CRL
Crown rump length
CST
Contraction stress test
CT
Chlamydia trachomatous
CVS
Chorionic villi sampling
D & C
Dilation & curettage
D & E
Dilation & evacuation
DIC
Disseminating intravascular coagulopathy
DI/DI
Dichorionic/diamniotic twins
EDC/EDD
Estimated date of confinement/estimated date of delivery
EFM
Electronic fetal monitoring
EFW
Estimated fetal weight
EGA
Estimated gestational age
EMB
Endometrial biopsy
ERT
Estrogen replacement therapy
FAVD
Forceps assisted vaginal delivery
FHR/FHT
Fetal heart rate/fetal heart tracing or tone
FL
Femur length
FLM
Fetal lung maturity
FM
Fetal movement
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FSE
Fetal scalp electrode
FSH
Follicle stimulating hormone
FTP
Failure to progress
GBS/GBBS
Group B beta streptococcus
GC
gonorrhea
GDM
Gestational diabetes mellitus
GIFT
Gamete intra-fallopian tube transfer
GnRH
Gonadotropin releasing hormone
G_P_
Gravida, para (TPAL – term, preterm, abortions, living children)
GTD
Gestational trophoblastic disease
HCG
Human chorionic gonadotropin
BHCG
Beta human chorionic gonadotropin (usually serum)
UHCG
Urinary human chorionic gonadotropin
HELLP
Hemolysis, elevated liver enzymes, low platelets
HGSIL
High-grade squamous intraepithelial lesion
HPL
Human placental lactogen
HPV
Human papilloma virus
HRT
Hormone replacement therapy
HSG
Hysterosalpingogram
HSV
Herpes simplex virus
I & D
Incision & Drainage
ICSI
Intracytoplasmic sperm injection
IUD
Intrauterine device
IUFD
Intrauterine fetal death
IUGR
Intrauterine growth retardation
IUI
Intrauterine insemination
IUP
Intrauterine pregnancy
IUPC
Intrauterine pregnancy pressure catheter
IVF
In vitro fertilization
LCP
Long, closed, posterior
LEEP/LOOP
Loop electrical excision procedure
LGA
Large for gestational age
LGSIL
Low grade squamous intraepithelial lesion
LH
Luteinizing hormone
LMP/LNMP
Last menstrual period/last normal menstrual period
LOA/LOT/LOP
Left occiput anterior/left occiput transverse/left occiput posterior
LTC
Long, thick, closed
LTCS/LVCS
Low transverse C-section/low vertical C-section
MFM
Maternal fetal medicine
MVU
Montevideo units
NST
Non-stress test
NSVD
Normal spontaneous vaginal delivery
NT
Nuchal translucency
NTD
Neural tube defect
OCP
Oral contraceptive pills
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OT
Occiput transverse
PCO/PCOD
Polycystic ovarian disease
PCT
Post-coital testing
PID
Pelvic inflammatory disease
PIH
Pregnancy induced hypertension
PMB
Postmenopausal bleeding
POC
Products of conception
POD/PPD
Post-operative day/postpartum day
PPH
Postpartum hemorrhage
PPROM
Preterm premature rupture of membranes
PROM
Premature rupture of membranes
PTL
Preterm labor
PUBS
Percutaneous umbilical blood sampling
PUPPPS
Pruritic urticarial papules and plaques of pregnancy
ROA/ROT/ROP
Right occiput anterior/right occiput transverse/right occiput posterior
ROM
Rupture of membranes
SBE
Self-breast exam
SGA
Small for gestational age
SROM
Spontaneous rupture of membranes
SSE
Sterile speculum exam
STD/STI
Sexually transmitted disease/sexually transmitted infection
SVE
Sterile vaginal exam
TAH
Total abdominal hysterectomy
TOA
Tubo-ovarian abscess
TOL
Trial of labor
TRIPLE TEST
MSAFP/HCG/Estriol
TVH
Total vaginal hysterectomy
US
Ultrasound
VAVD
Vacuum-assisted vaginal delivery
VB
Vaginal bleeding
VBAC
Vaginal birth after C-section
VAIN
Vaginal intraepithelial neoplasia
VIN
Vulvar intraepithelial neoplasia
THE APGAR SCORE
0
1
2
Respiratory effort
None
Weak, irregular
Good, crying
Pulse
None
<100
>100
Muscle tone
Flaccid
Some flexion
Well flexed
Color
Pale, blue
Body pink,
extremities blue
Pink
Reflex irritability
Nonresponsive
Grimace
Cry
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9. Spanish Lesson
Admission History and Physical
My name is
Me llamo
What is your name?
¿Como se llama usted?
What number pregnancy is this for you?
¿Que numeró embarazó es este para usted?
First?
¿Primero?
Second?
¿Segundo?
Third?
¿Tercero?
What is your due date?
¿Cual es su fecha de alivio?
Have you had ultrasounds?
¿Ha tenido sonogramas?
How many?
¿Cuantas?
How frequent are your contractions?
¿Que frecuenté son sus contriciones?
When did they start?
¿Cuando comenzaron?
Has your bag of waters broken?
¿Se le ha roto la Fuente / la bolas de agua?
What color was the fluid?
¿De que color era el fluido?
Are you bleeding?
¿Se la ha salido sangre?
How much?
¿Cuanto?
What color?
¿De que color?
Have you passed and mucous?
¿Se la ha salido moco o flujo?
Do you have any serious illnesses?
¿Tiene usted una enfermedad seria?
Have you had any operations?
¿Ha tenido usted operaciones (cirugía)?
Are you taking any medicine?
¿Usted tome cualquier tipo de medicina?
Are you allergic to any medications?
¿Tiene usted alergia a cualquier medicina?
Foods?
¿Comidas?
Have you been tested for diabetes this
pregnancy?
¿Le han hecho examinaciones de la sangre para la
diabetes este embarazo?
Any spotting/bleeding this pregnancy?
¿Le ha salido gotas de sangre o hemorragias con este
embarazo?
How much do you weigh now?
¿Cuanto pesa usted ahora?
Do you smoke?
¿Fuma usted?
How much?
¿Cuanto?
Breast or bottle?
¿Le va dar de pecho o de biberón?
Labor
We need to do a vaginal exam
Tenemos que hacer una examinación vaginal
Your cervix is ____ centimeters dilated
El cuello de la matriz esta abierto ___ centímetros.
Do you want some pain medication?
¿Quiera usted medicina ara el dolor?
You need to relax and breath with the
contractions
Usted necesita relajarse con los Dolores.
We are going to break your bag of water
Vamos a romper su Fuente (bolsa de agua).
We need to make your contractions more
frequent
Vamos a darle medicina para que le da contracciones
mas frecuenta.
Do you feel rectal pressure with the
contractions?
¿Cuando le da los Dolores, siente presión in el recto?
Do you feel the urge to push?
¿Siente usted como que necesita pujar?
Your cervix is completely dilated. It is time to
push.
El cuello de la motriz esta totalmente abierto. Es
tiempo pujar.
Take deep breaths
Respire profundo.
rev 5/1/2017
Hold it (your deep breath)
Detenga su aire.
Put your chin on your chest
Ponga su cabeza en su pecho
Push downward (on our bottom) like you are
having a bowel movement.
Puje para abajo como si va a regir.
Put your hands on your knees and pull them
back toward you.
Pone sus manos en sus rodillas y jale hacia usted.
Push very hard.
Puje muy fuerte.
Delivery
Don’t push now.
NO puje ahora.
Slow (pant) with your contractions
Sople con sus contracciones
It’s a boy/girl!
¡Es un niño / una niña!
Push for the placenta
Puje para la placenta.
Relax, let your legs fall to the sides
Relájese y deje que se caen sus piernas a los lados.
We are sewing up your episiotomy.
Vamos a poner puntos donde le cortando.
We’re going to give you medicine through your
IV to stop your contractions.
Vamos a darle medicina en la sonde para que se paren
los dolores.
We need to do an ultrasound
Necesitamos hacer una sonograma.
Your baby is coming: head/bottom/feet first
Su bebe viene: cabeza/nalga/pies primero.
Your blood pressure is high
Su presión esta alta.
Tell me immediately if you have a headache.
Dígame inmediatamente si tiene visión borrosa, or
epigástrica pain dolor de cabeza, la vista rrosa vista
doble, o dolor en el estómago.
This is consent for a Cesarean section.
Esta es permiso para una cesaría.
