Patient Addressograph
DISCHARGE/POSTPARTUM FORM
DELIVERY DATE HOSPITAL
DISCHARGE DATE
DELIVERY INFORMATION
DELIVERY AT_______WEEKS LABOR ANESTHESIA
■ VAGINAL ■ CESAREAN TUBAL STERILIZATION ■ YES ■ NO ■ NONE ■ NONE
■ SVD ■ PRIMARY (For ) NOTES ■ SPONTANEOUS ■ LOCAL/PUDENDAL
■ VACUUM ■ REPEAT - ELECTIVE ■ INDUCED ■ EPIDURAL
■ FORCEPS ■ REPEAT - UNSUCCESSFUL VBAC ■ AUGMENTED ■ SPINAL
■ EPISIOTOMY ■ INCISION ■ GENERAL
■ LACERATIONS ■ LOW TRANSVERSE ■ OTHER
■ VBAC ■ LOW VERTICAL
■ CLASSICAL DELIVERED BY
E
POSTPARTUM INFORMATION
COMPLICATIONS
■ NONE ■ HEMORRHAGE ■ INFECTION ■ HYPERTENSION ■ OTHER
L
DISCHARGE INFORMATION
NEONATAL INFORMATION MATERNAL INFORMATION
NAME OF BABY HGB/HCT LEVEL IMMUNIZATIONS GIVEN
SEX MEDICATIONS ■ ANTI-D IMMUNE GLOBULIN
■ FEMALE ■ MALE ■ RUBELLA
CIRCUMCISION
P
■ YES ■ NO ■ OTHER
FEEDING METHOD ■ BREAST ■ BOTTLE
BIRTH WEIGHT CONTRACEPTIVE METHOD (IF APPLICABLE)
DISPOSITION
■ HOME WITH MOTHER ■ IN HOSPITAL
FOLLOW-UP APPT
■ TRANSFER ■ NEONATAL DEATH DIAGNOSTIC STUDIES PENDING
■ STILLBIRTH ■ OTHER DATE
M
LOCATION
COMPLICATIONS/ANOMALIES
OTHER
SECONDARY DIAGNOSIS/PREEXISTING CONDITIONS
■ ASTHMA ■ HYPERTENSION
PEDIATRICIAN ■ DIABETES ■ OTHER
INTERIM CONTACTS
A
DATE COMMENT
S
PROVIDER SIGNATURE (AS REQUIRED)
Version 3. Copyright © 2002 The American College of Obstetricians and Gynecologists, 409 12th Street, SW, PO Box 96920, Washington, DC 20090-6920 AA197 12345/76543
POSTPARTUM VISIT
DATE ALLERGIES
LAB STUDIES REQUESTED MEDICATIONS/CONTRACEPTION
HGB/HCT LAST PAP TEST ■ DISPENSED
FEEDING METHOD INTERVAL CARE RECOMMENDATIONS
CONTRACEPTIVE METHOD FOR GENERAL HEALTH PROMOTION
POSTPARTUM DEPRESSION SCREENING
INTIMATE PARTNER VIOLENCE SCREENING
INTERIM HISTORY
PHYSICAL EXAM FOR REPRODUCTIVE HEALTH PROMOTION
E
BP WT
BREASTS ■ NORMAL
ABDOMEN ■ NORMAL
EXTERNAL GENITALS ■ NORMAL
VAGINA ■ NORMAL
L
CERVIX ■ NORMAL RETURN VISIT
UTERUS ■ NORMAL REFERRALS
ADNEXA ■ NORMAL
RECTAL-VAGINAL ■ NORMAL
■ ■
PAP TEST YES YES
P EXAMINED BY
COMMENT
M
A
S
PROVIDER SIGNATURE (AS REQUIRED)
