4. EXAMPLE
Dr bose good morning this is
Rajkumari lakshmi from ED NRS
Hospital calling to let you know that
Mrs sujata das 26 yrs old has been
admitted in early labor.
5. BACKGROUND
STATE THE ADMISSION DIAGNOSIS AND DATE OF
ADMISSION
STATE THE MEDICAL AND SURGICAL HISTORY
A BRIEF HISTORY OF THE TREATMENT TO DATE
6. EXAMPLE
A primi gravida mother came at ED around
5pm with chief complain of pain radiating
to thigh started on 9/7/17 since
4pm.Mother is 26 yrs old Gravida 1,LMP-
3/10/16 & EDD -10/7/17. Mother has no
complain in 1st trimester,2nd trimester and
third trimester .
7. Cont…
mother has no history of present and past
medical and surgical history. Mother has
no history of food and drug allergy.TT 1st
dose given on 20/11/16 ND 2nd dose on
21/12/17. Total wt gain during pregnancy
12 kg.
8. Cont…
USG done on 3/7/17(report-a single live viable
fetus with gestational age 39 weeks with vertex
presentation with adequate liquor. Blood
reports-bld gr (+ve),Rh (-ve),Hb-12 gm /dl, PPBS
fasting-120 mg /dl, VDRL- non reactive, urine
( sugar & albumin) not checked.
10. EXAMPLE
Mother has been monitor for 30 mint ,is
contracting every 10 mint each stay less than
20 second. she is dilated to 3 cm,70%
effaced, and station -1 and kept under
observation for progress of labor.
11. cont….
Now she has contraction every 5mint and
stay less than 20 sec when the Os is 4cm
dilated, 60% effacement .Baseline FHR is
140 b/mint, with average variability; there
are acceleration of 15 b/mint and no
deceleration. Her BP-130/80mmhg,pulse-
100, and resp-24.
12. RECOMMENDATION
Do you think we should:
-transfer the mother to?
-come to see the mother at this time?
- talk to the mother and family about
the status?
- ask to the consultant to see the
mother now?
- Other suggestion?
13. Cont…
Are any test needed:
If any change in treatment is ordered then ask:
- how often do you want vital signs?
- if the mother does not improve , when
you want us to call again?
14. EXAMPLE
May I transfer the mother to labor room?
What treatment would you like ?
Would you like any other lab test?
Mrs Das has contraction and stay less than
20 second when OS is 4cm dilated so I think
she would get benefit from oxytocin drip.
How would you like me to contact you.
