LUNGS: CTA. Disposition: Discharge home, continue monitoring, transfer units. Keep reading to see a case study using obstetric SOAP notes. Social History: Alcohol, tobacco use, recreational drug use, seatbelt safety, guns, domestic history, mental health history. Describe reflexes. Head, Ears, Ears, Nose, Throat (HEENT): Is the head normocephalic? Rx: Ibuprofen 600mg PO q 6 hours; Tylenol 1000mg PO q 6 hours PRN breakthrough pain, Micronor for contraception to start at 3 weeks, Pelvic rest, no heavy lifting for 6 weeks, Follow up in 2 weeks for postpartum depression clinic and 6 weeks for Postpartum visit with Dr. _____ or CNM ______. ... -Monitor the patient's height, weight, and vital signs at each prenatal visit. This guideline presents a chronological sequence of prenatal care that is based on scientific evidence, recommendations of … Initial Prenatal Visit (First OB antepartum) Subjective (S) Demographics: 19 yo G1P1000 @ 10w2d by irregular periods and unsure LMP. Dark purpleindicates items to be considered in … It's imperative that every student learn the basics for writing a SOAP note to become a health care provider like a physician or an Advanced Practice Nurse. Pain: Epidural PRN, the patient would prefer to decline pain medication at this time other than nitrous oxide. Fetus: Bimanual exam presents as approximately 9 wks gestation. Does the patient appear healthy and well-nourished? The nares are patent. If pregnant or nursing, consult with a qualified provider on an individual basis. Maternal Grandfather with Type II diabetes & neuropathy. Amenorrhea, increased frequency of urination, fatigue and breast tenderness began about four weeks ago. +2 DTR. Are there any murmurs or additional heart sounds? Presenting for OB care as a new patient, first antepartum visit. This article will break down the basics of how to write a SOAP note with obstetric examples. Caitlin Goodwin is a Certified Nurse-Midwife and birth nerd with 12 years in obstetric nursing. Healthcare providers need to be fluent in SOAP notes because it provides concise and complete documentation that should describe what you observed, what data you collected, and what you did. Do not stop or alter your current course of treatment. Is it distended? Are the spinal muscles symmetric? Chewable PNV PO daily with 800 mcg Folic Acid, Father died of colon cancer at age 54 (2009), Mother had cervical cancer (2010), is alive and stable. C/o nausea, first thing in the morning for the last two weeks. Yearly pap: Never had Pap, no Pap indicated at <21 yo per ACOG guidelines. HPI Believes LMP to be around: 1/24/2015 (“sometime between Valentine’s day and New Year’s Eve, probably the last week of January”). EDD 11/8/2015. Date Date Position Return visit (wks) Progress notes Progress notes Headache Bleeding Cramps/pain Swelling Fetal mvmt. Use their words ("I am having contractions"; "I think my water broke"). - Continue exercise as tolerated; walking, yoga, swimming, light weight-bearing, -Nausea and vomiting: Small, frequent meals, crackers & ginger ale, ginger, Sea-bands (acupressure), Vit b6 & Unisom, -Exercise- counseled regarding the importance of exercise, and safe fitness level. Labs: Write down the results of any labs that are relevant and available today (Urinalysis, blood sugar, labs and available from the prior visit). Rating pain 4/10 and managing pain well with nitrous oxide. Never smoker. SH (Social/Personal History) Single, attending college PT for nursing, works FT as a waitress, no drug use, 5-7 glasses of beer per week before pregnancy (1-2 at one time). EXTREMITIES: Without cyanosis, clubbing or edema. Neg CVA tenderness. Thanks for sharing. Tenderness? Are they clear to auscultation? Gait? The anterior shoulder delivered easily, and the postpartum oxytocin bolus initiated. Positive HPT: 3/17/2015 because she wanted to see if she “should have a green beer or not.” Healthy, well-nourished female. The placenta delivered spontaneously with gentle cord traction at 2132 and appeared to be intact upon visual inspection. NECK: Supple without lymphadenopathy. FHTs 150s-160s. Thus the above schedule of visits has been preprogrammed according to the above-recommended schedule. Alive. Imaging: Include any imaging results from the prior visit like the dating, Nuchal Translucency (NT), Anatomy or growth ultrasounds. As a Certified Nurse-Midwife, I use notes like these in everyday life. Muscular development? Abdomen: Is it soft? Maternal Grandmother died in MVA in 2017. Skin: Is it warm or cool to touch? Is there exudate or swelling from the tonsils? Convert to 17OHP to home injections if possible or continue weekly RN-only visits b. Continue taking prenatal vitamins 2. Past Medical History (PMH): Any medical condition in their past e.g., Hypertension, Diabetes, etc. What is the EDD or estimated gestational age? Are they feeling fetal movement? Does not have a cat, no litter box. Download high-quality Prenatal Chart for free. Unmarried, FOB involved. Describe any rash or tenderness. CC: Unintended pregnancy, pt is accepting but overwhelmed. Pt is not currently exercising. Date Date Position Return visit (wks) Progress notes Progress notes Headache Bleeding Cramps/pain Swelling Fetal mvmt. Dark purpleindicates items to be considered in … Think about their current situation and any other pertinent data. C/o nausea and vomiting in early AM and after large meals. History of spontaneous preterm birth a. The advanced tools of the editor will guide you through the editable PDF template. Unsure intercourse timing. Subjective data is the description that the patient gives you. eight … Mom and baby were left in stable condition, in skin to skin, attempting to breastfeed. Heart: Describe the rate and rhythm. - New OB Labs – T&S, CBC, G/C, RPR, Rubella, HBsAg, HIV, urine culture, HgbA1C, - Pap smear at age 21 yo per ACOG guidelines, - Fetal Genetic Screening – after counseling regarding options, pt has declined genetic screening (NT, 1st-trimester screen, NIPT). PRENATAL RECORD DATE OBJECTIVE EDC _____ G_____ P_____ EGA Cervix COMMENTS MD initials SUBJECTIVE Nausea/vomit. Include any important history such as hypertension, cancer, stroke, cardiac disease, diabetes. Obstetric History (ObHx): Provide their pregnancy history(Gravida/Para or GTPAL- Gravida Term Birth, Preterm Birth, Abortions, Living Children). Inguinal area is normal. Prenatal Care.pdf - ACTIVE LEARNING TEMPLATE Nursing Skill STUDENT NAME Care SKILL NAME_Prenatal REVIEW MODULE CHAPTER Description of Skill Providing. It cannot be measured. In addition, holding initial visits at this time may lead … Capillary refill? Prenatal Worksheet Prenatal Care Plan, Alberta Medical Association, October 2000 This prenatal worksheet outlines the examinations, investigations and counseling the physician or midwife should consider conducting during a woman’s pregnancy. This content is for informational purposes only and does not substitute for formal and individualized diagnosis, prognosis, treatment, prescription, and/or dietary advice from a licensed medical professional. Skin: Warm and dry without any rash. eight … Vital signs T and Tmax, P RR, BP (include ranges), ABD- Fundus firm, midline, u/2, nontender, Ext- +1 pitting edema, +2 DTRs, neg calf pain, 24 year old now G2P2022, s/p NSVD doing well PPD#2. General appearance: Is the patient alert and oriented? General appearance: The patient is alert, oriented X 4, in no acute distress. Extremities: Think of both upper and lower. Take full credit for your hard work! CC: Unintended pregnancy, pt is accepting but overwhelmed. Is there any discharge from the ears, eyes, or nose? Prenatal labs: Rubella immune, Rh positive. -Counseled regarding nutrition: The patient will attempt to include lean protein, dairy, and vegetables in her diet. No health issues. Is the patient in mild, moderate, or severe distress? S: Patient c/o intermittent, abdominal cramping. CVA tenderness? NEUROLOGICAL: Gross nonfocal. Prenatal Worksheet Prenatal Care Plan, Alberta Medical Association, October 2000 This prenatal worksheet outlines the examinations, investigations and counseling the physician or midwife should consider conducting during a woman’s pregnancy. Here are examples of what comes after Subjective data: Data that the health provider can directly observe. Are the pulses intact? The oropharynx is clear without lesions. Moist or dry? Very informative. Denies vaginal discharge, odor, bleeding, and cramping. The way to fill out the Prenatal form on the internet: To start the form, utilize the Fill & Sign Online button or tick the preview image of the document. Continue taking prenatal vitamins 2. ROM? No fetal movement. EBL 350 ml, fundus u/2, and firm. What do the mucous membranes look like of the mouth, nose, and throat? - Offer TDAP between 24-36 wks, offered flu vaccine when available. Denies dizziness, HA, visual disturbances, edema. The sinuses are nontender. The USPSTF strongly recommends screening for hepatitis B virus infection in pregnant … -When to call the office, the emergency line number. Initial Prenatal Visit (First OB antepartum), Demographics: 19 yo G1P1000 @ 10w2d by irregular periods and unsure LMP. Proper charting is an essential form of communication among healthcare professionals. Unmarried, FOB involved. Personal – Denies History of abuse, mental illness, depression, anxiety, or eating disorders. Apgars 8,9. Muscle spasms? -Avoidance of Cat litter, gardening with gloves.