SAMPLE CHARTING: Caesarian Delivery
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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
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