CS FORMAT NOTES

Endorsing a case of _______________, _____ year old Gravida ___ Para ___ (__-__-__-__) on -
her _____ weeks AOG, _______________, Filipino, _______________ from ________________________
________________________________ admitted for the __________ in NMMC due to ________________________
__________. ________________________
________________________
For the past medical history, patient has (no history of medical hospitalizations or surgical ________________________
admissions)/ (history of _________________________________________________________ ________________________
____________________________________________________________________________ ________________________
No known food and drug allergies. ________________________
________________________
For the family history, patient has (no history of heredofamilial disease)/ (history of ________________________
hypertension, diabetes mellitus, asthma, cancer) on her [maternal/paternal] [paternal] ________________________
[maternal] side. ________________________
________________________
For the personal and social history, patient is a ____________________ graduate, works as a ________________________
____________________ married to _______________ for ____ years who works as a ________________________
____________________. Patient is a non-smoker, non-alcoholic beverage drinker and denies ________________________
use of illicit drugs. ________________________
________________________
For the gynaecologic history, she had her menarche at _____ years old with subsequent ________________________
menses at [regular/irregular] intervals, _____ days in duration and consumes _____ pads per ________________________
day, [moderately/fully] soaked, [scanty/moderate/profuse] flow [associated/not associated] ________________________
with dysmenorrhea. She had her coitarche at _____ years old with _____ sexual partner. ________________________
Family planning used was/were________________________________________________. ________________________
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For the obstetrical history, patient is a Gravida ___ Para ___ (__-__-__-__). ________________________
Gravida Year Type of Delivered Term? Weight Where Complications? ________________________
delivery by /cephalic? delivered ________________________
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Reminder: Don’t rely on the format, ask your patient & your resident for the confirmation of the data, especially the SOAP & plan for the patient. 
Patients’ last menstrual period was on ____________________, __________ age of gestation, NOTES
with an expected date of confinement on ____________________. ________________________
________________________
st
She had her 1 prenatal check-up at ________________________________at _____ age of ________________________
gestation with _____ visits. She had _____ doses [completed her doses] of tetanus toxoid (TT) ________________________
vaccine. She took ferrous sulphate and/or multivitamins for _____ month. ________________________
________________________
For the History of Present Pregnancy, patient was admitted _________ on her _____ hour of ________________________
labor.________________________________________________________________________ ________________________
____________________________________________________________________________ ________________________
____________________________________________________________________________. ________________________
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For the patient’s physical examination, patient was examined conscious, coherent, ________________________
ambulatory, and not in respiratory distress with the following vital signs: BP _____ mmHg; ________________________
heart rate _____ beats per minute; respiratory rate _____ cycles per minute; temperature ________________________
_____ afebrile with a weight of _____ kg and height of _____ cm. ________________________
________________________
Skin of patient is warm and of good turgor. ________________________
For HEENT: [pink/pale] palpebral conjunctivae; anecteric sclera; moist lips and tongue ________________________
C/L: no retractions, equal chest expansion, clear breath sounds ________________________
CVS: adynamic precordium, distinct heart sounds, no murmur ________________________
Abdomen was examined ovoid with fundic height (FH) of _____ cm; fetal heart tone (FHT) of ________________________
_____ beats per minute at the [LLQ/LUQ/RLQ/RUQ] and estimated fetal weight of _____ ________________________
grams by Johnson’s rule with uterine contractions of [2/3/4] per 10 minutes, lasting ________________________
[40/50/60] seconds with [mild/moderate/strong] intensity. ________________________
L1 – breech cephalic ________________________
L2 – fetal back at [left/right] maternal side; fetal small parts at [left/right] maternal side ________________________
L3 – cephalic, [engaged/ not engaged] ________________________
L4 – cephalic prominence palpable on maternal [right/left]/ negative/ ________________________
empty ________________________
Position: LOA/LOP/LOT/ROA/ROP/ROT (Do not mention on endorsement unless questioned)! ________________________
:p ________________________
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On speculum exam, _________________________________________ ________________________
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On internal examination, cervix was _____ cm dilated; _____% effaced, _______________ ________________________
presentation, station _____, with [intact/ruptured] bag of water. ________________________
Extremities: [absence/presence] of edema [grade __] with good peripheral pulses ________________________
_______________________
Reminder: Don’t rely on the format, ask your patient & your resident for the confirmation of the data, especially the SOAP & plan for the patient. 
Admitting Impression: Pregnancy Uterine, _____ weeks age of gestation, __________ NOTES
presentation, in active labor, G___ P___ (__-__-__-__) ________________________
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____________________________________________________
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Plan is for possible normal spontaneous vaginal delivery after _____ hours
________________________
But if with abnormal labor pattern or with non-reassuring fetal heart rate pattern, proceed to
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caesarean section.
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IVF of D5LR 1 liter was started at ___ drops per minute
________________________
The following laboratories were requested: CBC with PC, HbSAg, BT, UA
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CBC revealed:
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WBC of ___/ul
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Hgb of ___g/dl
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Hct of ___ %
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Platelet ___
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Blood type of ___ Rh+
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____________________________________________________________________________ ________________________

____________________ ________________________
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Patient subsequently underwent
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____________________________________________________________________________ ________________________
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With a Preoperative Diagnosis of: ________________________
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____________________________________________________________________________
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____________________________________________________________________________
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Intraoperative findings of: ________________________
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____________________________________________________________________________
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____________________________________________________________________________
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Postoperative Diagnosis: ________________________
____________________________________________________________________________ ________________________
____________________________________________________________________________ ________________________
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Final diagnosis:
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G___ P___ (___-___-___-___)
________________________
Pregnancy uterine, full term, delivered to a live baby [boy/girl], AS _____, BW _____
_______________________
kg via ________________________________________________________________.

Reminder: Don’t rely on the format, ask your patient & your resident for the confirmation of the data, especially the SOAP & plan for the patient. 
1 hour postop, {S} patient had [no subjective complaints/complains of ____________], on NOTES
catheter with __cc, [yellow, blood-stained, dark yellow} urine; with the following vital signs {O}
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BP _____ mmHg; HR _____ bpm; RR _____ cpm; T _____ C; Skin of patient is warm and of
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good turgor. For HEENT: [pink/pale] palpebral conjunctivae; anecteric sclera; moist lips and
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tongue; C/L: no retractions, equal chest expansion, clear breath sounds; CVS: adynamic
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precordium, distinct heart sounds, no murmur; abdominal exam: wound dressing intact,
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normo/hypoactive bowel sounds, uterus: _____ weeks size, well contracted; GUT:
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{normal/minimal} lochia rubra; Extremities: [absence/presence] of edema [grade __] with
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good peripheral pulses; {A} status postoperatively for 1 hour, clinically guarded; {P} plan is to
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let the patient under NPO status temporarily for __ hours, regulate IVF at __ gtts/min, IVTF
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D5LR 1L + 20U oxytocin at 30gtts/min, D5LR 1L + 10U oxytocin at 30 gtts/min, D5LR 1L at 30
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gtts/min.
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_____ Hours postop, {S} patient had [no subjective complaints/complains of ____________], ________________________

on catheter with ___cc, [yellow, blood-stained, dark yellow} urine, flatus___? With [O] stable ________________________
vital signs: BP _____ mmHg, HR _____ bpm, RR _____ cpm, T _____ C; Skin of patient is warm ________________________

and of good turgor. For HEENT: [pink/pale] palpebral conjunctivae; anecteric sclera; moist lips ________________________

and tongue; C/L: no retractions, equal chest expansion, clear breath sounds; CVS: adynamic ________________________
precordium, distinct heart sounds, no murmur; abdominal exam: wound dressing intact, ________________________

normo/hypoactive bowel sounds, uterus: _____ weeks size, well contracted, GUT: ________________________

{normal/minimal} lochia rubra; Extremities: [absence/presence] of edema [grade __] with ________________________

good peripheral pulses; {A} status postoperatively for ___ hour, clinically guarded; {P} plan is ________________________

to let the patient on general liquids, then soft diet once with flatus, to continue IV ________________________

medications, repeat CBC; remove FBC at ____, and to refer the patient if unable to void, ________________________

exclusive breastfeeding, encourage the patient to ambulate and to counsel the patient for ________________________

family planning. ________________________

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Reminder: Don’t rely on the format, ask your patient & your resident for the confirmation of the data, especially the SOAP & plan for the patient. 