Maternity Admission Note
Patient Name: Emmy Green
MRN: 123456
Date: October 8, 2059
Time: 09:30 AM
Attending Physician: Dr. [Your Name]
Gestational Age: 38 weeks
Chief Complaint:
The patient presents for evaluation and admission for labor.
History of Present Illness:
Emmy Green is a 28-year-old G1P0 (first pregnancy, no previous births) who arrived at the labor and delivery unit with regular contractions occurring every 5 minutes for the past 2 hours. She reports the contractions started at home and have become progressively more intense. The patient also reports a small amount of blood show.
Obstetric History:
Medical History:
Surgical History:
Allergies:
Medications:
Review of Systems:
General: No fever, chills, or weight loss.
Cardiovascular: No chest pain or palpitations.
Respiratory: No shortness of breath or cough.
Gastrointestinal: No nausea or vomiting.
Genitourinary: Normal urinary output; no dysuria.
Neurological: No headaches or visual disturbances.
Physical Examination:
Vital Signs:
BP: 120/75 mmHg
HR: 80 bpm
RR: 16 breaths/min
Temp: 98.6°F
General: Alert and oriented, in mild distress due to contractions.
Abdomen: Soft, non-tender, fundal height consistent with gestational age.
Fetal Heart Rate: 140 bpm, reassuring.
Pelvic Exam:
Assessment:
Plan:
Admit to labor and delivery.
Initiate continuous fetal monitoring.
Provide IV access and hydration as needed.
Discuss pain management options with the patient.
Continue to monitor labor progress.
Signature:
Dr. [Your Name], MD
Attending Physician
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