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)