dictations

Discharge Summary Dictation Template

"Hello, this is your name dictating a discharge summary on..."

Patient Name"

Acct. #:

Date of admission:

Date of discharge:

Attending:

Primary dx:

Secondary dx:

Primary procedure:SVD, cesarean section

Secondary procedure:
epidural analgesia, spinal anesthesia, artificial rupture of membranes, fetal scalp electrode, intrauterine pressure catheter, pitocin augmentation of labor, Induction of labor with cytotec, induction of labor with foley bulb, laboratory studies

Hospital course: For details of her admission history please see previously dictated H&P. She was induced using cytotec / foley bulb / pitocin . (or she progressed spontaneously in labor).

List if she had artificial or spontaneous rupture of membranes
List if a fetal scalp electrode or IUPC were placed and for what reason

If Vaginal delivery - She progressed through labor and subsequently had a spontaneous vaginal delivery / vacuum assisted vaginal delivery / Forceps assisted vaginal delivery which was uncomplicated (or complicated by _____). For details of her delivery, please see delivery dictation.

If Cesarean - She subsequently was noted to have give indication for cesarean section and was taken back for a cesarean section which

was uncomplicated (or complicated by_____). For details of the surgery please see op note previously dictated.

Post delivery the patient did well. On Post delivery day one, her hemoglobin was ____, her blood pressures were normal / abnormal. Her exam was unremarkable (if a C/S, state her incision was clean dry and intact).

List any unusual issues that happened postpartum

On postpartum day ___ she was ambulating, tolerating a regular diet, had voided, her bleeding was minimal, and her pain was well controlled. She was breast / formula feeding. She had a desire to go home. Based on the patients status and the fact she is meeting all goals for discharge, it was decided she could safely be discharged home. Dr. Attending’s name agreed with the decision to discharge.

Discharge instructions:
Discharge the patient home on a regular / diabetic diet. Her level of activity is as tolerated. She is to avoid intercourse for 6 weeks. She is told to call the office for bleeding greater than 2 pads in 1 hour, a temperature greater that 100.4, severe pain, or vomiting unrelieved by medications.

She was discharged home on percocet 5/325 dispense number (give at least #30), scheduled ibuprofen 800mg dispense #24
(list colace, iron sulfate, or antihypertensives if these are to be started)

For contraception, she chooses_____ (if she received depo-provera then state, “She received depo provera prior to discharge.”)

She will return for a postpartum exam in 6 weeks at Anmed Family practice , Carolina OB/Gyn. (if she had a C/S or developed a hypertensive disorder of pregnancy, “She will return in 1 week for an incision check / BP check”)

This concludes the dictation of Patient Name.

Please send a copy of this dictation to AnMed Family Practice / Carolina OB/Gyn / Anderson OB/Gyn

Admission H&P Dictation Template

"Hello, this is your name dictating an admission H&P on..."

Patient Name:

Medical Acct. #:

Date of admission:

Attending:

Chief Complaint: contractions, Rupture of membranes, etc

HPI: pt is a Age y/o   G Gravida P Term,Preterm, Abortions,Living at ___ weeks by ultrasound at weeks which is (consistent / not consistent) with her last menstrual period whose pregnancy is complicated by List ALL prenatal concerns . She presents to labor & delivery with presenting complaint. Give brief pertinent negative/positives to the presenting illness.

She denies/endorses:
          Contractions
          Leakage of fluid
          Vaginal bleeding
          Gross fetal movement
          Nausea or vomiting
          Headache
          Visual changes
          Epigastric pain

Pt was followed by AnMed Family Practice, Carolina OB/Gyn for prenatal care.

Prenatal Labs:
          RH positive / negative
          Antibody screen negative / positive
          Rubella immune / non-immune
          RPR nonreactive / reactive
          Hepatitis B negative / positive
          Chlamydia negative / positive
          Gonorrhea negative / positive
          Urine culture negative / positive
          GBS negative / positive
          Pap negative / ASCUS +- HRHPV / LSIL / HSIL
          HIV negative / positive
          Quad Screen negative / positive
          Glucola _____   ( give 3hr results as well, if 1 hr ≥140)
          Most recent hgb was _____ on ____Date_____
          Most recent platelets was ______ on ____Date_____

Past Medical History:

Past Surgical History:

OB History:
(List each delivery, miscarriage, etc.)
In year she had a spontaneous vaginal delivery / c-section of a male / female at gestational age with list any complications

GYN History:
Age of menarche / Frequency of her menses / Length of her menses / history of STDs / history of abnormal paps

Family History:
Must give at least 2 disease processes. ex. “No family history of cancer or hypertension”
(cannot say “noncontributory” or “none”)

Social History:
Denies / endorses
          smoking
          alcohol
          illicit drug use

Medications:

Allergies:
List the allergy and the associated reaction

Physical Exam:
     Vital Signs-
     General-
     HEENT-
     Lungs-
     Heart-
     Abdomen-
     Cervical exam-
     Extremities-

Fetal Assessment:
Comment on baseline, variability, presence of accels, characterize decels, overall impression of the strip, frequency of contractions

Imaging:
Comment on bedside ultrasound presentation, outline any ultrasounds available that her relevant to her current admission

Assessment:
Age y/o   G Gravida   P Term,Preterm, Abortions,Living at ___ weeks in active labor, for induction of labor secondary to (post dates, preeclampsia, SROM) , etc.

Plan:
-Admit to Labor and delivery for active management
-For management, I will ( observe, start medium dose Pitocin, place 25 mcg vaginal cytotec)
-Will monitor closely contractions and plan on a cervical exam in 2 or 4 hrs or for any change in patient status.  We will start pitocin if not continuing to labor
-List what you will give for GBS prophylaxis IF GBS positive
-Will order CBC, Type and hold, Urinalysis, RPR, (HELLP labs if they have a hypertensive disorder) and follow up on results when available
-The plan has been discussed with Attending name

This concludes the dictation of Patient Name

Please send a copy of this dictation to AnMed Family Practice / Carolina OB/Gyn / Anderson OB/Gyn

Circumcision Dictation Template

"Hello, this is your name dictating a procedure note on..."

Patient Name:

Medical Acct. #:

Date of Procedure:

Description of Procedure:
Prior to the procedure informed consent was obtained from the mother and the consent form was complete. The identity bracelet on the baby was double checked.

The penis was examined and there was no evidence of hypospadias or chordee. The baby was prepped and draped in the usual sterile fashion. The dorsal nerve of the penis was infiltrated with 0.4 cc of 1% Lidocaine at both the 10 and 2 o'clock position. The foreskin was identified and grasp at the 10 and 2 o'clock positions with straight hemostats. Using a third hemostat the adhesions between the glans and foreskin were lysed. A third hemostat was then used to clamp approximately half the length of the foreskin along the mid line.The hemostats at 10 and 2 o'clock positions were removed. Scissors were used to cut along the clamp line. The foreskin was then reduced down over the glans and further adhesions were removed using a blunt probe. The position of the urethra was again confirmed.

Selection of a 1.1 / 1.3 Gomco was used based upon the size of the glans and the foreskin. The bell was placed over the glans. The foreskin was brought up over the bell and then up through the Gomco clamp apparatus. The clamp was then tightened after appropriate positioning was confirmed. Total clamp time was approximately 1 minute. A #10 scalpel was used to remove the foreskin from the bell. After one minute the Gomco was released and the edge of the foreskin was reduced off the bell. A good cosmetic result was obtained. Bleeding was minimal. The penis was dressed with Vaseline gauze and the baby was returned to the regular nursery.

The procedure was supervised by Attending name .

This concludes the dictation of Patient Name .

Delivery Note Dictation Template

"Hello, this is your name dictating a procedure note for..."

Patient Name:
Acct. #:
Date:
Attending:

This Age y/o G Gravida P Term,Preterm, Abortions,Living was complete and pushing at time. She was prepped and draped in the usual sterile fashion. (if an episiotomy - “A mediolateral / medial episiotomy was cut to expedite the delivery”.)

At time, a viable ---lb --oz , male / female infant was delivered in the vertex position over an intact perineum / midline episiotomy / mediolateral episiotomy . The head was delivered followed promptly by the anterior and posterior shoulders with steady gentle downward pressure (a nuchal cord was identified and was reduced / delivered through)

Infant's nose & mouth were suctioned at the perineum and the baby was placed on the mother’s chest , given to the waiting nursery nurses. APGARs were ____ and ____.

Pitocin was administered after delivery of the baby. An intact placenta with 3 vessel cord was delivered at time. It was inspected and found to be grossly intact. The cervix and vaginal walls were examined. The perineum was inspected and found to have no defects, or list defects. (list any repair that was done)

EBL was amount in c.c.. There were no complications. Cord blood was collected and sent to the nursery. The pt was in stable condition having tolerated the procedure well. Sponge and needle counts were correct. The infant was in stable condition and left to bond with the mother.

Delivery was attended and supervised by Attending Name.

This concludes the dictation on Patient Name . This is your name .