H&P Triage Templates

*MEDITECH INSTRUCTIONS:*
1. Click “Enter New” (on the right-hand navigation menu)
2. Search “Student History & Physical,” add to favorites
3. Click “Add Section” (on the right-hand navigation menu)  search “History & Physical – blank,” add to favorites
4. Copy & paste the template below into the “H&P-BLANK” section of your note
5. Press F2 on the keyboard to tab through all the parts of the history that need to be changed for your individual patient
6. Click “Quick Save”

CHIEF COMPLAINT: []

HPI:

[] yo G[]P[] at [] []/7 wga by [last menstrual period consistent with ][] week ultrasound who presents to labor and delivery triage with []. Patient denies contractions, vaginal bleeding, loss of fluids, reports [normal] fetal movement.

Prenatal care complicated by []. Patient has been receiving prenatal care at [] with Dr. [].

Estimated due date []. Last menstrual period [].

OB HISTORY:

G1 [year] [vaginal or c/s] at [] weeks. [Gender] [baby weight], [no complications including diabetes, preterm, hypertension, preeclampsia]

G2 [year] [vaginal or c/s] at [] weeks. [Gender] [baby weight], [no complications including diabetes, preterm, hypertension, preeclampsia]

G3 [year] [vaginal or c/s] at [] weeks. [Gender] [baby weight], [no complications including diabetes, preterm, hypertension, preeclampsia]

G4 [year] [vaginal or c/s] at [] weeks. [Gender] [baby weight], [no complications including diabetes, preterm, hypertension, preeclampsia]

GYN HISTORY:

Menses: Menses at [], periods [regular], lasting [] days

STDs: patient reports [no] history of STI’s, []consistent with chart review

Abnormal Paps: [no] documented abnormal pap smears, patient denies

PMH: []

PSH: []

FAMILY HISTORY: [No family history of birth defects or genetic disorders]

SOCIAL HISTORY: [No] tobacco, [no] alcohol, [no] illicit drugs

MEDICATIONS: [Prenatal vitamins]

ALLERGIES: [] ([]rash, []anaphylaxis)

ROS: [All systems reviewed and negative except as noted in HPI.]

PHYSICAL EXAM:

Vital signs reviewed

[] (ENTER “VITAL SIGNS - LAST 24 HR RANGE” AND “VITAL SIGNS - FIRST DOCUMENTED” HERE - click “Data Formats” on right-hand menu & search for these)

Gen: [Alert and awake]

HEENT: [Normocephalic, no periorbital edema]

CV: [Warm and well perfused]

Resp: [Aerating well, symmetric expansion]

Abd: [Soft, gravid, fundal height appropriate]

Extremities: [No clubbing, no cyanosis], [] edema on lower extremities

Pelvic: [Adequate pelvis] [EFW]

Cervix: []

Skin: [Supple, intact, no rashes]

Neuro: [Alert & oriented x3]

Psych: [Appropriate mood and affect]

MEDICAL DECISION MAKING:

Prenatal Labs: Blood type [], antibody screen [negative], R[I], RPR[NR], HIV[-], HBV[-], []HCV[-], GC/CT[-], 1hr GTT [], GBS [-]

External fetal heart tracing: Baseline HR [] with moderate variability, [] accelerations, [no] decelerations

Tocometry: [Contractions]

Bedside U/S: []

[ENTER “ALL LAB/MICRO/RAD LAST 16 HRS” AND “CBC-FISHBONE ONLY” HERE – click “Data Formats” on right-hand menu & search for these]

ASSESSMENT:

1) [] yo G[]P[] at [] []/7 WGA by LMP c/w [] weeks ultrasound here for [].

2) Active labor

3) Reassuring fetal status

4) Cephalic presentation

5) GBS[]

PLAN:

- Admit to Labor & Delivery for []

- R/B/A of delivery and blood transfusion discussed and consents signed

- Routine labs and IVF

- Will augment with Pitocin as needed and tolerated

- Epidural PRN

- Routine intrapartum monitoring

Patient care plan discussed with attending physician Dr. [] and []he/she agrees