Postpartum Inpatient Daily Progress Note

Postpartum Inpatient Daily Progress Note

Date/Time: [Date and time of note entry]

Postpartum Day (PPD): [PPD#] (Include POD# if post-cesarean)

Delivery: [Delivery date; mode: SVD / operative vaginal / cesarean; gestational age at delivery]

Key History: [Gravida/para; pertinent pregnancy or delivery complications relevant to today's care—e.g., hypertensive disorder, hemorrhage with EBL, infection, anemia, laceration repair]

Subjective

[Interval events since last note and overnight concerns—fever, bleeding, pain, headache/visual changes, dyspnea/chest pain, nursing concerns as reported] (Document what was actually reported or assessed. If a key safety domain was not assessed, note explicitly.)

[Recovery milestones: ambulation, diet tolerance, voiding, flatus/BM; lochia character/amount; pain level and regimen effectiveness; feeding plan and lactation status with any latch/supply issues or lactation consult involvement; mood and adjustment. If formal screening performed, record tool name, score, and interpretation. Include contraception preference if discussed.]

Objective

Vitals: [Temp, HR, BP, RR, SpO2; include 24h range if relevant]

Exam: (Include only systems actually examined today.)

• [General appearance]
• [Uterine fundus: firmness, height relative to umbilicus, tenderness]
• [Lochia on inspection] (If assessed)
• [Perineum/laceration status] or [Cesarean incision status] (Include applicable item; note approximation, drainage, erythema, hematoma as relevant)
• [Breast exam] (If clinically indicated)
• [Extremities: edema, tenderness, asymmetry] (If VTE concern)

Data: [Relevant labs or imaging—Hgb/Hct trend, preeclampsia labs, cultures; note if pending] (Omit if none obtained.)

Assessment & Plan

(List active or high-risk issues first. Use bolded problem heading, brief assessment, and bulleted plan. If information is unavailable, state what is missing and how it will be obtained. Do not copy forward without verifying current status.)

[Bleeding / Anemia]

[Assessment: bleeding status, lochia trend, Hgb/Hct, symptoms]

• [Monitoring, transfusion threshold, repeat labs timing]
• [Therapy: iron, uterotonics, other interventions]

[Hypertensive Disorder Surveillance]

[Assessment: BP trends, symptoms, lab status]

• [BP monitoring frequency and escalation parameters]
• [Medications and adjustments]
• [Follow-up BP check timing and patient education]

[Infection]

[Assessment: suspected/confirmed source, vitals, exam, cultures]

• [Antibiotic therapy: agent, dose, duration]
• [Pending diagnostics and follow-up plan]

[Pain Management]

[Assessment: pain level, regimen effectiveness, side effects]

• [Analgesic plan with dosing; multimodal strategy]
• [Bowel regimen as needed]

[Wound/Perineum Care]

[Assessment: incision or perineal repair status]

• [Local care and monitoring plan]
• [Follow-up for suture/staple removal if applicable]

[VTE Prophylaxis]

[Assessment: risk factors and current prophylaxis]

• [Mechanical and/or pharmacologic prophylaxis with agent, dose, duration]

[Lactation Support]

[Assessment: feeding method, latch/supply issues]

• [Lactation consult involvement; feeding plan and resources]

[Mood / Mental Health]

[Assessment: mood/adjustment; screening tool, score, interpretation if completed]

• [Counseling provided; referrals or safety plan if indicated]

[Contraception Plan]

[Assessment: patient preference, eligibility, timing]

• [Method selected; orders/consents; bridge method and follow-up]

[Other Active Issues]

[Assessment of chronic disease or other condition with postpartum implications]

• [Management plan, medications, monitoring, referrals]

Routine Postpartum Care / Recovery Status

[Summary of milestones met: ambulation, diet, voiding, bowel function, pain control, feeding, education completed]

• [Continue routine care: activity, perineal/abdominal care, stool regimen, vaccinations, newborn care coordination]

Discharge Planning

• [Anticipated discharge: today / tomorrow / pending barrier]
• [Barriers and plan to address]
• [Follow-up: routine postpartum visit timing; BP check if indicated; specialty follow-ups]
• [Education completed/pending: warning signs, medications, wound care, feeding resources]
• [Prescriptions and DME/home services if applicable]