H&P for Triage - Admitted or Discharged

*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”

History & Physical for Triage Patient

CHIEF COMPLAINT: []

HPI:

[] yo G[]P[] at [] []/7 wga by [last menstrual period consistent with ][] week ultrasound (EDD [ ]) presents to labor and delivery triage with []. Denies [contractions,] [vaginal bleeding,] [loss of fluids]. Reports [normal] fetal movement.

She has been receiving prenatal care with Dr. []. Her pregnancy has been complicated by [].

OB HISTORY:

G1 [year] [NSVD][CD] at [] weeks, [fe]male, [weight], [no complications]

G2 [year] [NSVD][CD] at [] weeks, [fe]male, [weight], [no complications]

G3 [year] [NSVD][CD] at [] weeks, [fe]male, [weight], [no complications]

G4 [year] [NSVD][CD] at [] weeks, [fe]male, [weight], [no complications]

GYN HISTORY:

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

STIs: patient reports [no ]history of [STIs][, consistent with chart review]

Abnormal Paps: patient [denies] abnormal Pap smears

PMH: [Denies]

PSH: [Denies]

FAMILY HISTORY: [Denies family history of birth defects or genetic disorders], [denies family history of bleeding or clotting disorders]

SOCIAL HISTORY: [Denies] tobacco, alcohol, or illicit drug use[; intimate partner violence screening negative]

MEDICATIONS: [Prenatal vitamin]

ALLERGIES: [NKDA] [(reaction)]

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

PHYSICAL EXAM:
[Vital signs reviewed]

BMI: []

Gen: [Alert and awake]

HEENT: [Normocephalic, no periorbital edema]

CV: [Warm and well perfused]

Resp: [Aerating well, symmetric expansion]

Abd: [Soft, gravid],EFW []# by Leopolds

**Pelvic: [Adequate] pelvis, cervix []/[]/[], [] position, [] consistency**

Extremities: [No] edema on lower extremities

Skin: [Supple, intact, no rashes]

Neuro: [Alert & oriented x3]

MEDICAL DECISION MAKING:

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

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

Tocometry: q [] min contractions

Bedside U/S: [cephalic]

[Labs/Imaging/Studies]

ASSESSMENT: [] yo G[]P[] at [] []/7 wga by [last menstrual period consistent with ][] week ultrasound presents with []. [Not in ]active labor with reassuring fetal status[ in cephalic presentation].

[2.] []

[3.] GBS[]

[4.] Rh status: [positive] [negative]

[5.] Rubella: [immune] [non-immune]

PLAN: [IF DISCHARGED FROM TRIAGE]

- Discharge to home

- Labor precautions reviewed

- Pre-eclampsia precautions discussed

- Follow up with primary obstetrician

- Red flags to call MD or return to hospital discussed with patient who voiced understanding

- Plan of care reviewed with patient and questions answered

- Patient care plan discussed with attending physician, Dr. []

PLAN: [IF ADMITTED FROM TRIAGE]

- Admit to labor & delivery for []. [The patient was counseled on the slightly increased risk of fetal morbidity/mortality at this gestational age, however, the benefits of delivery prior to 39 weeks outweigh the risks at this time.]

- R/B/A reviewed and consents obtained for blood, delivery[, and Cytotec]

- Admit labs drawn

- Continuous fetal heart rate and contraction monitoring

- [Start Pitocin as clinically indicated]

- [Start PCN for GBS prophylaxis]

- [Consult anesthesia for epidural as requested by patient]

- [Desires infant circumcision, consents signed][Declines infant circumcision]

- Labor & delivery course discussed with patient; questions answered

- Patient care plan discussed with attending physician Dr. []

[Name], MD

Tulane OB/GYN PGY-[]