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DATE OF DELIVERY
• • •
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BABY NAME, SEX AND WEIGHT
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MODE OF DELIVERY
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LABOR AND DELIVERY ISSUES
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IF VD - DEGREE OF LACERATION
• • •
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LENGTH OF ACTIVE LABOR (HRS)
• • •
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LENGTH OF SECOND STAGE (HRS)
• • •
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PREGNANCY ISSUES:
• • •
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OTHER PREGNANCY ISSUES
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MATERNAL POSTPARTUM ISSUES
• • •
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OTHER MATERNAL POSTPARTUM ISSUES
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NEONATAL ISSUES
• • •
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OTHER NEONATAL ISSUES
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FEEDING
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OTHER FEEDING ISSUES
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EXAM
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SBP
• • •
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DBP
• • •
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WEIGHT
• • •
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URINE
• • •
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EXAM - APPEARANCE
• • •
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EXAM - CV
• • •
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CV EXAM COMMENTS
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EXAM - BREAST
• • •
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BREAST EXAM COMMENTS
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EXAM - THYROID
• • •
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THYROID EXAM COMMENTS
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EXAM - INCISION
• • •
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INCISION COMMENTS
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EXAM - PELVIS
• • •
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PELVIC EXAM COMMENTS
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EXAM - DIASTASIS
• • •
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DISTASIS COMMENTS
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EXAM - EDEMA
• • •
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EDEMA COMMENTS
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ADDITIONAL COMMENTS RE EXAM
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CONTRACEPTION
• • •
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CONTRACEPTIVE COMMENTS
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ASSESSMENT & PLAN
• • •
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ADDITIONAL ASSESSMENT & PLAN
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CPT
• • •
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ICD9
• • •
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OTHER CPT AND ICD9
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