Inpatient Pregnancy Chart 1 DS

 Inpatient sample charts / Sample Inpatient cases / Inpatient DRG coding / DRG coding sample charts

DISCHARGE SUMMARY

Diagnoses:

•             (Principal) NORMAL DELIVERY     

•             PRECIPITATE LABOR         

•             SECOND DEGREE PERINEAL LACERATION                

                                2nd degree episiotomy cut  

•             BREAST FEEDING MOTHER            

•             RH NEGATIVE     

                                Received rhogam for bleeding 1st tri 8/2/21

•             MAJOR DEPRESSIVE DISORDER, RECURRENT EPISODE, IN FULL REMISSION              

                                On celexa

Male

Delivery Type: Vaginal, Spontaneous

 

Birth date/time:               13/11/21              2:25 AM 

Living status: Living

Sex: Male

Apgar 1min: 8    Apgar 5min: 9  

Weight: 3240 g

 Labor and Delivery Complications

Labor Complications: None

Shoulder Dystocia: No 

 

Primary Procedures:

Male

Delivery Type: Vaginal, Spontaneous 

 

Secondary Procedures:

Male

Placenta Removal: Expressed

Anesthesia:

Method: Local

Local Medication Used: Lidocaine 1%

Volume (mL): 10                                              

Episiotomy/Lacerations

Episiotomy: Median        Repaired with: 3-0 Polysorb, 2-0 Polysorb

Episiotomy Laceration Comment: Anal sphincter evaluated by MD Chu, found intact

Perineal lacerations: None            

 

Summary of Hospital Course:

Patient was admitted for: Active Labor

Her intrapartum course was: significant for precipitous delivery 

Her post delivery course was: unremarkable

Complications: None

 

Subjective:

This patient is known to me as I attended her birth. No unusual complaints. Rhogam given. Seen by LSW this AM.

Pain relieved with medications

Breastfeeding   Experienced breastfeeding mother, no complaints

Bleeding normal

Voiding  normal

Diet and Bowel function  tolerating a regular diet

Mobility Walking without difficulty

 

Physical Exam at discharge:

BP 106/50  | Pulse 73  | Temp 99.2 °F (37.3 °C)  | Resp 18  | Ht 1.778 m (5' 10")  | Wt 76.8 kg (169 lb 5 oz)  | SpO2 98%  | Breastfeeding Yes  | BMI 24.29 kg/m²

 

General Appearance:  Alert, well appearing and in no distress

Breasts:   Soft

Abdomen:  soft, fundus well contracted and nontender

Perineum:  sutures intact

Extremities:  no tenderness in the calves or thighs and no significant edema

 Birth Control Plan: hx infertility 

Condition on discharge:

Patient is medically stable for discharge and agrees with the plan of care.

 

Discharge Disposition:

Discharged home