Discharge Summary Template

# Discharge Summary after Spontaneous Labor

Hospital Course:
[] year-old G[]P[] presented to labor and delivery at []/7 wga, was found to be in labor and therefore admitted in expectation of delivery. Labor course[ was augmented with oxytocin and][ was uncomplicated]. She delivered a viable [fe]male infant with Apgars of [], weighing [] grams. The delivery [went well and was uncomplicated][was complicated by][]. See delivery note for details.

She was transferred to the postpartum floor in stable condition. Postpartum course was [un]complicated[ by gestational HTN/pre-eclampsia/blood loss anemia/anemia of chronic disease/ iron deficiency anemiareceived 24 hours of IV magnesium for seizure prophylaxis, which she tolerated well.] [Her admission H/H was [ ]/[ ] and was [ ]/[ ] on postpartum day 1, she was discharged home with iron.] By postpartum day [], her pain was well controlled, she was tolerating a regular diet, ambulating without difficulty, and voiding spontaneously. Her lochia was appropriate. She was afebrile and her vital signs were otherwise stable and within normal limits. She was counseled on birth spacing and options for birth control methods, and she [will discuss her options with her primary OB][desires ][ which was ordered prior to discharge]. [Infant circumcision was performed prior to discharge.][ She declined infant circumcision].

As she met all necessary postpartum milestones, she was discharged to home on postpartum day []. [Patient was counseled on the quantity of the opioid pain medication prescribed on discharge and that she has the option to fill the prescription in a lesser quantity. She was also informed of the risks associated with the opioid prescribed. ]Postpartum instructions were given, including but not limited to: preventive measures for postpartum depression, preeclampsia precautions, red flags to call her doctor or to return to the ED, and instructions to follow up with her primary OB for outpatient postpartum care.]

# Discharge Summary after Induction of Labor

Hospital Course:
[] yo G[]P[] presented to labor and delivery for [elective ][medically indicated ]induction of labor at [] wgafor [ ]. Patient received [misoprostol/cervidil for cervical ripening] [, labor was augmented with oxytocin,][ and was uncomplicated]. She delivered a viable [fe]male infant with Apgars of [], weighing [] grams. The delivery [went well and was uncomplicated][was complicated by][]. See delivery note for full details.

She was transferred to the postpartum floor in stable condition. Postpartum course was [un]complicated[ by gestational HTN/pre-eclampsia/blood loss anemia/anemia of chronic disease/iron deficiency anemia]. [She received 24 hours of IV magnesium for seizure prophylaxis, which she tolerated well.] [Her admission H/H was [ ]/[ ] and was [ ]/[ ] on postpartum day 1, she was discharged home with iron.] By postpartum day [], her pain was well controlled, she was tolerating a regular diet, ambulating without difficulty, and voiding spontaneously. Her lochia was appropriate. She was afebrile and her vital signs were otherwise stable and within normal limits. She was counseled on birth spacing and options for birth control methods, and she [will discuss her options with her primary OB][desires ][ which was ordered prior to discharge]. [Infant circumcision was performed prior to discharge.][ She declined infant circumcision].

As she met all necessary postpartum milestones, she was discharged to home on postpartum day []. [Patient was counseled on the quantity of the opioid pain medication prescribed on discharge and that she has the option to fill the prescription in a lesser quantity. She was also informed of the risks associated with the opioid prescribed. ]Postpartum instructions were given, including but not limited to: preventive measures for postpartum depression, preeclampsia precautions, red flags to call her doctor or to return to the ED, and instructions to follow up with her primary OB for outpatient postpartum care.]

# DC Sum after Labor then C-section or IOL then C-section

Hospital Course:
[] yo G[]P[] presented to labor and delivery at [] wga with [a complaint of ] [induction of labor for [] ]. Labor course consisted of [cervical ripening with misoprostol/ cervidil] and augmentation with [ ] and [was complicated by][NRFHT/arrest of dilation],[The decision was made to proceed to the OR for Cesarean delivery]. Patient delivered a viable [female][male] infant with Apgars of [], weighing [] grams, by Caesarean section. The delivery [went well and was uncomplicated][was complicated by][]. See operative note for full details.

She was transferred to the postpartum floor in stable condition. Postpartum course was [un]complicated[ by gestational HTN/pre-eclampsia/blood loss anemia/anemia of chronic disease/ iron deficiency anemia]. [She received 24 hours of IV magnesium for seizure prophylaxis, which she tolerated well.] [Her admission H/H was [ ]/[ ] and was [ ]/[ ] on postpartum day 1, she was discharged home with iron.] By postpartum day [], her pain was well controlled, she was tolerating a regular diet, ambulating without difficulty, and voiding spontaneously. Her lochia was appropriate. She was afebrile and her vital signs were otherwise stable and within normal limits. She was counseled on birth spacing and options for birth control methods, and she [will discuss her options with her primary OB][desires ][ which was ordered prior to discharge]. [Infant circumcision was performed prior to discharge.][ She declined infant circumcision].

As she met all necessary postpartum milestones, she was discharged to home on postpartum day []. Patient was counseled on the quantity of the opioid pain medication prescribed on discharge and that she has the option to fill the prescription in a lesser quantity. She was also informed of the risks associated with the opioid prescribed. Postpartum instructions were given, including but not limited to: preventive measures for postpartum depression, preeclampsia precautions, red flags to call her doctor or to return to the ED, and instructions to follow up with her primary OB for outpatient postpartum care.]

# Discharge Summary after Scheduled C-section

Hospital Course:
[] yo G[]P[] presented to labor and delivery at [] wga for scheduled Cesarean delivery[ for][]. She underwent a [repeat][primary][ low transverse] Cesarean delivery, and delivered a viable [fe]male infant with Apgars of [], weighing [] grams. The delivery [went well and was uncomplicated][was complicated by][]. See operative note for full details.

She was transferred to the postpartum floor in stable condition. Postpartum course was [un]complicated[ by gestational HTN/pre-eclampsia/blood loss anemia/anemia of chronic disease/ iron deficiency anemia]. [She received 24 hours of IV magnesium for seizure prophylaxis, which she tolerated well.] [Her admission H/H was [ ]/[ ] and was [ ]/[ ] on postpartum day 1, she was discharged home with iron.] By postpartum day [], her pain was well controlled, she was tolerating a regular diet, ambulating without difficulty, and voiding spontaneously. Her lochia was appropriate. She was afebrile and her vital signs were otherwise stable and within normal limits. She was counseled on birth spacing and options for birth control methods, and she [will discuss her options with her primary OB][desires ][ which was ordered prior to discharge]. [Infant circumcision was performed prior to discharge.][ She declined infant circumcision].

As she met all necessary postpartum milestones, she was discharged to home on postpartum day []. Patient was counseled on the quantity of the opioid pain medication prescribed on discharge and that she has the option to fill the prescription in a lesser quantity. She was also informed of the risks associated with the opioid prescribed. Postpartum instructions were given, including but not limited to: preventive measures for postpartum depression, preeclampsia precautions, red flags to call her doctor or to return to the ED, and instructions to follow up with her primary OB for outpatient postpartum care.]

# Discharge Summary after Gyn Surgery

Hospital Course:
[] yo G[] underwent [] for management of []. Her surgery went well and was [uncomplicated]. Please see previously dictated operative note for full details. She was transferred to the floor in stable condition. The remainder of her hospital course was [essentially uncomplicated]. By postoperative day [], her pain was well controlled, she was tolerating a regular diet, ambulating without difficulty, and voiding spontaneously. She was afebrile and her vital signs were otherwise stable[ and within normal limits]. As she was meeting all necessary postoperative milestones, she was discharged home on postoperative day []. [She was counseled on the quantity of the opioid pain medication prescribed on discharge and that she has the option to fill the prescription in a lesser quantity. ][She was also informed of the risks associated with the opioid prescribed. ][She was given instruction on safe disposal / and or return to pharmacy of unused pills. ][Discharge instructions were given, including but not limited to: red flags to call her doctor or to return to the ED, postoperative outpatient follow up.]

# BEFORE all Hospital Course:

Admission date: []

Admission diagnosis: []

Discharge Date: []

Discharge diagnosis: []

Procedure performed: []

Consultations: []

# After all Hospital Courses

Discharge instructions
1. Postpartum instructions given and red flags to return to ER discussed

Activities: Gradually resume normal activities and avoid over exertion. Continue to ambulate regularly while at home. Observe strict pelvic rest (nothing in the vagina--i.e. no fingers, no douching, no tampons, no sex) for 6 weeks following delivery. Patient may shower and take sponge baths, but she should avoid tub baths for 6 weeks after delivery. No drinking or driving while on narcotic pain medications.

Recommendations: Call the office for a temperature greater than or equal to 100.4 F, severe uncontrolled pain, vaginal bleeding saturating two menstrual pads per hour for greater than two hours in a row, headache, changes in vision, upper belly pain, difficulty breathing, new or worsening swelling, or any other concerns.

[Due to the risks of narcotic medications, please do not take for longer than 7 days. If you do not need your full prescription, you may ask for fewer pills than your prescription is written for. Please flush leftover tablets or return them to the pharmacy. If you have concerns regarding your prescription, please ask your provider.]

2. Diet: []Regular

3. Pelvic rest 6 weeks

4. Activity: Gradually resume normal activity

5. Follow Up with Dr. [] in [] weeks

6. Discharge Medications:

[] PNV [and iron ]daily

[] Motrin 800mg q8hrs prn for pain

[] Tylenol 1000mg q8hrs prn for pain

[] Oxycodone 5mg q6hrs prn for pain