7 am.docx

2
7 am 8 am 10 am 12 nn 2 pm 3 pm Received with an IVF of D5 LRS 1 L + 10 units of oxytocin at around 300 cc & regulated at 42 gtts/min; consumed @ 11:30 am and replaced with D5 NM 1 L + 10 units of oxytocin and regulated to 42 gtts/min; With Foley catheter connected to urine bag with yellowish output and removed @ 11 am With wound dressing dry; With mild post operative pain as claimed With slight lochia rubra BP = 140/100 mmHg; T=38.4 C; Tepid sponge bath done for 15 minutes & cold compress placed over the forehead Visited by Dra. _______ with orders Breastfed her baby per demand Consumed 200 mL of water Sponge bath and perineal care done BP = 120/80 mmHg; T = 37.4 C Endorsed for continuity of care SAMPLE CHARTING: Normal delivery

Transcript of 7 am.docx

7 am8 am10 am12 nn2 pm3 pmReceived with an IVF of D5 LRS 1 L + 10 units of oxytocin at around 300 cc & regulated at 42 gtts/min; consumed @ 11:30 am and replaced with D5 NM 1 L + 10 units of oxytocin and regulated to 42 gtts/min; With Foley catheter connected to urine bag with yellowish output and removed @ 11 amWith wound dressing dry; With mild post operative pain as claimedWith slight lochia rubraBP = 140/100 mmHg; T=38.4 C; Tepid sponge bath done for 15 minutes & cold compress placed over the foreheadVisited by Dra. _______ with ordersBreastfed her baby per demandConsumed 200 mL of waterSponge bath and perineal care doneBP = 120/80 mmHg; T = 37.4 CEndorsed for continuity of careSAMPLE CHARTING: Normal deliveryTime

7 am9 am10 am10:30 am12 nn3 pmReceived with an IVF of D5 LRS 1 L + 10 units of oxytocin on around 300 cc & regulated at 42 gtts/min; consumed and removed @ 11 amWith slight lochia rubraBP = 130/80 mmHgVisited by Dra. ________ with ordersInitial breastfeeding done / Breastfed her baby as demandConsumed a bowl of rice gruel & 200mL of waterSponge bath and perineal care doneEndorsed for continuity of care