Obstetric (Delivery/Postpartum) Discharge Summary

Header Fields

• Patient: [Patient name]; [Medical record number]; [Date of birth] (Omit any subfield that is truly unavailable rather than inserting placeholder text.)
• Encounter: [CSN or FIN]; [Facility]; [Unit] (Omit any subfield that is truly unavailable.)
• Admission: [Admission date and time]
• Discharge: [Discharge date and time]
• Author: [Author name], [Role]; [Attestation date and time]
• Attending: [Attending of record at discharge]; [Primary obstetric provider if different] (Omit if same as attending or not applicable.)

Summary

[One to three sentence synopsis including gravida/para if clinically relevant; gestational age at delivery; reason for admission; mode of delivery with date and time; key postpartum complications or state uncomplicated postpartum course if core domains addressed below; disposition]

Reason for Admission

[Brief narrative presenting indication such as active labor, prelabor rupture of membranes, scheduled cesarean delivery, induction for specified indication, or antepartum complication requiring delivery]

• Antepartum conditions affecting postpartum plan: [Hypertensive disorder status]; [Diabetes status]; [Thrombophilia or anticoagulation status]; [Anemia]; [Infection risks or exposures] (Include only conditions that materially affect postpartum management.)
• Prenatal statuses relevant to postpartum care: [Blood type and Rh]; [Antibody screen status]; [Group B Streptococcus status and whether intrapartum antibiotics were given]; [Infectious screening results per institutional practice] (Include only if documented and relevant.)

Discharge Diagnoses

• [Principal discharge diagnosis] (Place first; include severity or features when applicable such as preeclampsia with severe features. Do not upgrade beyond documented criteria.)
• [Secondary diagnosis 1] (Include only conditions treated or active during admission.)
• [Secondary diagnosis 2]
• [Additional diagnoses as applicable]

Procedures

• [Delivery procedure]: [Date and time]; [Mode: vaginal / operative vaginal with instrument type / cesarean delivery with incision type]; [Indication if operative or cesarean] (Write procedure names in full without abbreviations.)
• [Anesthesia or analgesia]: [Epidural / spinal / combined spinal-epidural / general anesthesia / local / none]; [Date and time]; [Complications if any]
• [Laceration repair]: [Degree: none / first / second / third / fourth]; [Date and time]; [Repair performed: yes / no] (If details are not documented in delivery note, state explicitly.)
• [Postpartum procedures if applicable]: [Dilation and curettage / intrauterine balloon tamponade / uterine artery embolization / blood transfusion with units and date/time / intrauterine device insertion with type / tubal sterilization with method / other]; [Brief indication for each]

Delivery Details

(For postpartum readmissions, provide a concise historical recap of delivery including mode, date/time, and major complications, then focus the Hospital Course on readmission problems.)

• Labor course: [Induction and/or augmentation methods with dates/times]; [Rupture of membranes date and time with fluid description if pertinent]; [Fetal status concerns prompting intervention if applicable]; [Intrapartum antibiotics and indication] (Omit labor details for scheduled cesarean without labor.)
• Birth: [Date and time of birth]; [Mode of delivery: vaginal / operative vaginal (forceps / vacuum) / cesarean delivery]; [Indication for operative or cesarean delivery if applicable]
• Quantitative blood loss: [QBL in mL] (Objective value only; interpretation belongs in Hospital Course.)
• Placenta: [Delivery status: spontaneous / manual removal]; [Sent to pathology: yes / no; reason if sent]
• Perineum or incision: [Laceration degree or cesarean incision details]; [Repair completed: yes / no]
• Complications: [Shoulder dystocia: present / absent]; [Postpartum hemorrhage: present / absent; suspected etiology if present] (Do not imply absence by omission; state explicitly.)

Hospital Course

[Overall trajectory statement summarizing the inpatient course in one to two sentences; explicitly note complications or absence thereof]

(Organize by problem when complications are present. For uncomplicated stays, a brief chronological narrative is acceptable if core postpartum domains below are addressed. Include dates and times for key events.)

Problem-Oriented Course

(Include one block per active problem. Omit this subsection entirely for uncomplicated stays if core domains below are addressed.)

[Problem name]

• Objective data: [Pertinent vitals including blood pressures with dates/times]; [Hemoglobin/hematocrit trend with dates]; [Laboratory or imaging findings with dates]; [Medications given with start/stop dates]
• Clinical course and response: [Concise narrative of evolution, interventions, and response]
• Discharge plan and follow-up owner: [Medications and targets]; [Home monitoring plan]; [Named clinician or service responsible for follow-up and timeframe]

Core Postpartum Domains

(Address even in uncomplicated stays using concise statements.)

• Hemodynamic stability and bleeding: [Uterine involution and fundal tone]; [Lochia description]; [Bleeding status]
• Blood pressure course: [Blood pressure ranges and trends]; [Hypertensive disorder status]; [Antihypertensive medications if used]
• Pain control: [Analgesic regimen]; [Effectiveness]; [Opioid counseling provided if applicable]
• Ambulation and venous thromboembolism prophylaxis: [Ambulation status]; [Mechanical and/or pharmacologic prophylaxis if indicated]
• Voiding and bowel function: [Voiding status]; [Bowel function and regimen if issues present] (Include only if clinically relevant.)
• Incision or perineum: [Cesarean incision or perineal repair status]; [Signs of infection or hematoma: present / absent]
• Lactation and feeding plan: [Breastfeeding / pumping / formula]; [Lactation supports provided]; [Supplementation plan if applicable]
• Mood screening: [Screening tool and result]; [Resources or referrals provided if indicated]

Pertinent Results

(Include only results materially affecting discharge decisions, medication choices, or follow-up.)

• [Test name]: [Date]; [Key values]; [Interpretation or plan]
• [Additional results as applicable]

Pending Results

• [Pending study name]: [Date obtained]; [Responsible clinician or service]; [Expected follow-up mechanism]

(If no results are pending, state: No results pending at discharge.)

Consultations

(Include only consultations with actionable discharge recommendations. Omit section if no consultations obtained.)

• [Consulting service]: [Reason for consult]; [Key recommendation impacting discharge plan]

Condition at Discharge

[Vital stability]; [Functional status including ambulation and diet tolerance]; [Pain control adequacy]; [Obstetric status including bleeding and fundal tone or incision status]; [Impact of newborn disposition on maternal plan if applicable]

Disposition and Services

• Disposition: [Home / home with services / transfer / against medical advice]
• Home services arranged: [Visiting nurse for blood pressure or wound checks / lactation support / other] (Omit if none.)
• Equipment provided: [Breast pump; blood pressure cuff; wound care supplies; anticoagulation supplies; other] (Omit if none.)
• Language and materials: [Preferred language]; [Written instructions provided in preferred language: yes / no]

Discharge Medications

(Provide a reconciled, complete list. For each medication include name, dose, route, frequency, indication, and duration or stop date when applicable.)

• New: [Medication; dose; route; frequency; indication; duration] (For opioids, include maximum daily limits and counseling on sedation, constipation, safe storage, and disposal. For antihypertensives, include blood pressure targets and managing clinician. For anticoagulants, include duration, monitoring, and refill owner.)
• Continued: [Medication; dose; route; frequency; indication]
• Changed: [Medication; new dose or frequency; reason for change]
• Stopped: [Medication; reason for discontinuation]

(Note breastfeeding considerations when clinically significant. If home medication history is incomplete, explicitly state limitations.)

Follow-up Plan

• Routine postpartum care: [Contact within three weeks; comprehensive visit by twelve weeks; clinician or service; location or telehealth; scheduled date/time if known]
• Hypertensive disorders: [Blood pressure evaluation within 72 hours to 7–10 days depending on severity]; [Home monitoring plan]; [Owner responsible] (Include only if applicable.)
• Gestational diabetes: [75-gram oral glucose tolerance test at 4–12 weeks postpartum]; [Owner responsible] (Include only if applicable.)
• Cesarean incision: [Incision check timing]; [Owner] (Include only if applicable.)
• Severe perineal laceration: [Pelvic floor follow-up and symptom monitoring plan]; [Owner] (Include only if applicable.)
• Mood concerns: [Early contact resources]; [Emergency pathway]; [Owner] (Include only if applicable.)
• [Additional problem-specific follow-up with explicit ownership as applicable]

Warning Signs Communicated

[Documentation that urgent maternal warning signs were reviewed with patient: heavy vaginal bleeding; fever or chills; worsening abdominal or pelvic pain; severe headache or vision changes; chest pain or trouble breathing; leg pain or swelling; thoughts of harming self or baby]; [Written materials provided: yes / no]; [Language of materials]

Newborn Information

(Include when relevant to maternal care coordination. Omit if not affecting maternal discharge planning and a separate newborn summary exists.)

• Infant: [Infant name or identifier]; [Sex]; [Birthweight with units]
• Feeding plan: [Breastfeeding / pumping / formula]; [Supplementation plan if applicable]
• Newborn disposition: [Rooming-in / NICU]; [Impact on maternal plan if applicable]
• Pediatric follow-up: [Clinic or provider]; [Date/time if scheduled] (Include only if maternal coordination needed.)

(For multiples, include one entry per infant.)