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    ACOG Postpartum Discharge Form

    Uploaded by

    nandipati ramnadh
    ACOG POST PARTUM DISCHARGE FORMAT

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    ACOG Postpartum Discharge Form

    Uploaded by

    nandipati ramnadh
    405 views2 pages
    ACOG POST PARTUM DISCHARGE FORMAT

    Copyright

    © © All Rights Reserved

    Available Formats

    PDF, TXT or read online from Scribd

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    ACOG POST PARTUM DISCHARGE FORMAT

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    405 views2 pages

    ACOG Postpartum Discharge Form

    Uploaded by

    nandipati ramnadh
    ACOG POST PARTUM DISCHARGE FORMAT

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 2

    Patient Addressograph

    DISCHARGE/POSTPARTUM FORM
    DELIVERY DATE HOSPITAL

    DISCHARGE DATE
    DELIVERY INFORMATION
    DELIVERY AT_______WEEKS LABOR ANESTHESIA
    ■ VAGINAL ■ CESAREAN TUBAL STERILIZATION ■ YES ■ NO ■ NONE ■ NONE

    ■ SVD ■ PRIMARY (For ) NOTES ■ SPONTANEOUS ■ LOCAL/PUDENDAL

    ■ VACUUM ■ REPEAT - ELECTIVE ■ INDUCED ■ EPIDURAL

    ■ FORCEPS ■ REPEAT - UNSUCCESSFUL VBAC ■ AUGMENTED ■ SPINAL

    ■ EPISIOTOMY ■ INCISION ■ GENERAL

    ■ LACERATIONS ■ LOW TRANSVERSE ■ OTHER

    ■ VBAC ■ LOW VERTICAL


    ■ CLASSICAL DELIVERED BY

    E
    POSTPARTUM INFORMATION
    COMPLICATIONS
    ■ NONE ■ HEMORRHAGE ■ INFECTION ■ HYPERTENSION ■ OTHER

    L
    DISCHARGE INFORMATION
    NEONATAL INFORMATION MATERNAL INFORMATION
    NAME OF BABY HGB/HCT LEVEL IMMUNIZATIONS GIVEN
    SEX MEDICATIONS ■ ANTI-D IMMUNE GLOBULIN
    ■ FEMALE ■ MALE ■ RUBELLA
    CIRCUMCISION
    P
    ■ YES ■ NO ■ OTHER
    FEEDING METHOD ■ BREAST ■ BOTTLE
    BIRTH WEIGHT CONTRACEPTIVE METHOD (IF APPLICABLE)
    DISPOSITION
    ■ HOME WITH MOTHER ■ IN HOSPITAL
    FOLLOW-UP APPT
    ■ TRANSFER ■ NEONATAL DEATH DIAGNOSTIC STUDIES PENDING
    ■ STILLBIRTH ■ OTHER DATE
    M
    LOCATION
    COMPLICATIONS/ANOMALIES
    OTHER

    SECONDARY DIAGNOSIS/PREEXISTING CONDITIONS


    ■ ASTHMA ■ HYPERTENSION
    PEDIATRICIAN ■ DIABETES ■ OTHER

    INTERIM CONTACTS
    A

    DATE COMMENT
    S

    PROVIDER SIGNATURE (AS REQUIRED)

    Version 3. Copyright © 2002 The American College of Obstetricians and Gynecologists, 409 12th Street, SW, PO Box 96920, Washington, DC 20090-6920 AA197 12345/76543
    POSTPARTUM VISIT
    DATE ALLERGIES

    LAB STUDIES REQUESTED MEDICATIONS/CONTRACEPTION

    HGB/HCT LAST PAP TEST ■ DISPENSED

    FEEDING METHOD INTERVAL CARE RECOMMENDATIONS

    CONTRACEPTIVE METHOD FOR GENERAL HEALTH PROMOTION

    POSTPARTUM DEPRESSION SCREENING

    INTIMATE PARTNER VIOLENCE SCREENING

    INTERIM HISTORY

    PHYSICAL EXAM FOR REPRODUCTIVE HEALTH PROMOTION

    E
    BP WT

    BREASTS ■ NORMAL

    ABDOMEN ■ NORMAL

    EXTERNAL GENITALS ■ NORMAL

    VAGINA ■ NORMAL

    L
    CERVIX ■ NORMAL RETURN VISIT

    UTERUS ■ NORMAL REFERRALS

    ADNEXA ■ NORMAL

    RECTAL-VAGINAL ■ NORMAL

    ■ ■
    PAP TEST YES YES
    P EXAMINED BY

    COMMENT
    M
    A
    S

    PROVIDER SIGNATURE (AS REQUIRED)

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