Comprehensive Postpartum Follow-Up Visit Note

Date/Time: [date and time]

Patient: [patient name or identifier]

Clinician: [clinician name and credentials]

Delivery Date: [date] | Weeks Postpartum: [calculated]

Delivery: [vaginal / operative vaginal / cesarean]; [key complications if any / none]; [post-discharge events: ED visits / readmissions / none]

Subjective

[Brief visit synopsis stating weeks postpartum, delivery mode, and patient's primary concerns for today]

Recovery & Symptoms: [Bleeding/lochia trajectory]; [Pain: location, severity, management]; [Wound or perineal healing]. Red flags [present: specify / absent]. (Explicitly document presence or absence of: fever, severe headache or vision changes, chest pain or dyspnea, leg swelling, heavy bleeding, foul discharge, wound concerns.)

Infant Feeding: [Feeding method: breastfeeding / pumping / formula / combination]; [Lactation concerns and maternal goals if applicable]. (If not breastfeeding, document reason neutrally.)

Mood & Adjustment: [Patient-reported mood, anxiety, sleep, bonding, support]. Screening: [tool name], score [numeric], interpretation [negative / positive / elevated], action [reassurance / referral / safety plan / other]. (If positive for self-harm or thoughts of harming infant, document explicit safety assessment and plan. If screening deferred, state reason and follow-up plan.)

Sexual Health & Contraception: [Sexual activity status]; [Dyspareunia: present / absent / not assessed]; [Pregnancy intentions and timing]; [Current or planned contraceptive method].

Pelvic Floor & Elimination: [Urinary symptoms]; [Bowel function]; [Pelvic pressure or prolapse symptoms]. (Omit if not addressed.)

Chronic Condition Follow-up: [Relevant conditions: hypertensive disorder with home BP readings and symptoms / GDM with postpartum glucose testing status / anemia / thyroid / mental health / substance use]. (Include only conditions relevant to this patient.)

Social & Safety: [IPV screening result (conducted privately)]; [Psychosocial concerns: housing, food, transportation, insurance, return-to-work as relevant].

Objective

Vitals: [BP (repeat if elevated), HR, temp, weight as relevant]

Exam: [Pertinent findings from systems examined today, tailored to symptoms and indications: general appearance, breast, abdomen/incision, perineum, pelvic exam, extremities as indicated]. (Document if pelvic exam declined or deferred with reason. Note chaperone presence per institutional policy.)

Data: [Relevant labs or imaging reviewed or ordered, with interpretation]

Assessment

(Number problems in order of clinical priority with brief status statement and supporting data.)

1. [Problem 1]: [Status and key supporting data]
2. [Problem 2]: [Status and key supporting data]
3. [Problem 3]: [Status and key supporting data]

Plan

(Organize by problem. Include diagnostics, medications, counseling, referrals, and return precautions as applicable to each.)

[Problem 1]: [Specific actions: diagnostics, therapeutics, counseling, referrals]

[Problem 2]: [Specific actions]

[Problem 3]: [Specific actions]

Return Precautions: [Hemorrhage, infection, hypertensive symptoms, VTE signs, mood crisis warning signs reviewed with patient]

Care Coordination: [PCP identified or referral to establish care]; [Specialty follow-ups]; [Insurance or access concerns addressed]

Follow-up: [Next appointment: routine / expedited]; [Responsibility for pending results]; [Crisis resources provided if applicable]

Time-based billing (if applicable): [Total clinician time]