Obg and Gynaecology notes and examination in hospital

1. Patient Name
MR Number
DOB
Date
Time
Op Note:
• Look in your pocket. There should be a Maxwell’s in
there. Follow the format given to you.
Things to Know:
• OB is a taxing, but rewarding rotation.
• Be sure to ask for opportunities to catch babies and
do surgical procedures—there should be ample
opportunity.
• You will be tired from being on call… make the most
of your time at the hospital.
• Proper OR etiquette applies to OB as well. Scrub up
and retract that bladder!
• PATs are pre-op physical exams performed in the
Surgical Admitting Center: be thorough and quick.
• Practice your knots so you can be a star when you
get suture something.
• Always carry an energy bar or food in your lab coat
pocket
• Pee BEFORE going to the OR. It is bad form to
scrub out routinely for bathroom breaks.
OB/Gyn
Labor and Delivery (every 2 hours) Progress Note—MSIII
S: 24 hour events… Pt. Subjective assessment of contractions, abd. pain,
changes in vision, discharge, bleeding, SOB, leg pain, edema.
O: Vitals: Tmax / Tcurrent / bp / hr / resp / O2 sats /accucheck
I/O: last 8hr- ‘in” (PO, IV)/ “outs” (urine, stool)
last 24hr- ‘in” (PO, IV)/ “outs” (urine, stool)
Labs:
Meds: (including Mag, pitocin)
Fetal montior: ctx/ fetal hr/ variability/ accel.,decel.
Exam: GEN:
HEENT:
CV:
PULM:
ABD:
EXT:
NEURO:
STERILE VAGINAL EXAM:
STERILE SPECULUM EXAM:
A/P: ______ y/o G__P__ female at ____weeks, ___/7 days gestation with
PMHx of _______ now ________ .
List problems and plan to treat each.
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2. SOAP Note—Gyn/Onc Service
Complete these notes before rounds.
This is essentially a surgical service. Thus, the surgery format for
SOAP note should be used.
Op Note:
Look in your pocket. There should be a Maxwell’s n there. Follow
the format given to you.
Patient Name
MR Number
DOB
Patient Name
MR Number
DOB
Date
Time
OB/Gyn
Post-partum Progress Note—MSIII
S: 24 hour events… Pt. Subjective assessment
of N/V/F/C, pain, wound, discharge, SOB, leg
pain, bowel activity. (It will be similar to a surgery
note).
O: Vitals: Tmax / Tcurrent / bp / hr / resp / O2
sats /accucheck
I/O: last 8hr- ‘in” (PO, IV)/ “outs” (urine, stool)
last 24hr- ‘in” (PO, IV)/ “outs” (urine, stool)
Labs:
Meds:
Exam: GEN:
HEENT:
CV:
PULM:
ABD:
EXT:
NEURO:
GU:
WOUND:
A/P: ______ y/o G__P__ female with PMHx of
_______ now with ________ s/p _________
(NSVD, forceps/vaccuum-assist., C/S ), post-
partum day ________.
List problems and plan to treat each.
SOAP Note—Gyn/Onc Service
This is essentially a surgical service. Thus, the surgery format for SOAP
note should be used.
Date
Time
Op Note:
Look in your pocket. There should be a Maxwell’s in there. Follow the
format given to you.
Books:
• Beckmann’s Obstetrics and Gynecology (covers
everything on the test – read this book once!)
• Maxwell’s Essentials in Obstetrics and Gynecology
(“required” but not the best for test prep)
• Blueprits in OB Gyn (for review only)
• Essentials of Obstetrics and Gynecology by Hacker and
Moore (better comprehensive book)
• First Aid for the OB/Gyn Clerkship
• Netter’s Obstetrics, Gynecology, and Women’s Health
(great for visual learners)
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