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. Page 1 of 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) Page 2 of 2