OB History Endorsement Format

ENDORSEMENT FORMAT
Endorsing a case of ______. , __ __ years old, Gravida

___ Para ___ (________ ), on her ____ weeks AOG,
Roman Catholic/________________, Filipino,
__________________from
_________________________________was admitted
for the _________ time in NMMC due to
_______________________________
For the past medical history
Skin of px is warm and of good turgor.

For HEENT:
palpebral conjunctiva, an icteric
sclerae
Chest and Lungs: with equal chest expansion, clear
breath sounds, no retraction
] No history of previous hospitalizations.
Cardiovascular: adynamic precordium, distinct heart

sounds, no murmur
] No known food and drug allergies.
Abdomen examined
] Denies medical illnesses.
For the family history

[ ] Absence of HPN, Diabetes mellitus, Cancer nor
Asthma.
For the personal and social history
ovoid w/ fundic height of _____cm

L1 Breech
L2 Fetal back on maternal side
Fetal small parts on maternal
L3 Cephalic floating
L4 Cephalic prominence right
Fetal heart tone of _____beats per minute w/ uterine

contraction _____ per 10 minutes , ____ seconds
duration, ___________ intensity.
For the gynecologic history
For the Obstetric history
For the history of present pregnancy

Last menstrual period:
Previous menstrual period:
Age of Gestation:
wks
Expected date of confinement:
[ ] Prenatal check-up at OB OPD / BHC started at
___wks age of gestation for __ visits and received ___
doses of tetanus toxoid.
[ ] FeSO4 and multivitamins were given taken once a
day for __ months.
For physical examination
Px is examined conscious, coherent, ambulatory
and not in respiratory distress w/ the ff vital signs:
Blood pressure of
/
mmHg
(______cardic w/ the )
Heart rate of
bpm
(_______pnea w/ the ) Respiratory rate of
cpm
(A febrile w/ the ) Temperature of
C
Weight ______kgs.
On Internal examination
Cervix ___cm dilated
_____% effacement,
Cephalic presentation
Station
Bag of water
Extremities
Absence of edema.
Good peripheral pulses
The Admitting Impression
Plan: for
IVF of D5LR 1 liter was started at 30
drops per minute
Following laboratory were requested:
CBC revealed:
WBC of
/ul
Hgb of
g/dl
Hct of
%
Platelet
Blood type of
_____
Rh+
Partograph
Px subsequently underwent
Preoperative Diagnosis of:
Intraoperative findings of:
Postoperative Diagnosis:
OPD SOAP FORMAT

BP:
AOG:
LMP:
EDC:
INTERNAL EXAMINATION
GUT:
EXT:
S:
PAST MEDICAL HISTORY
( ) HPN
()Thyroid disorders
() DM
() Food and drug allergies
() Asthma () Major and Minor Operations
() Cardiovascular disorders
WORK-UP RESULTS
CBC
BT
HBsAG
A:
FAMILY HISTORY
( ) HPN
()Thyroid disorders
() DM
() Cancer
() Asthma
() Multi-fetal Preganacies
() Cardiovascular disorders
PERSONAL AND SOCIAL HISTORY
Educational attainment:
Current Job/Empoyment:
Marital Status and number of years:
Age of partner:
Job of partner
Vices:
GYNECOLOGIC HISTORY
Menarche:
Interval:
Duration:
Amount: # pads per day
Symptoms: () dysmenorrheal
Coitarche:
# of Sexual Partners
Family Planning Method
OB HISTORY
G_P_(_ _ _ _)
G#- year, place of confinement, AOD, manner of
delivery, BW, complications
O:
PHYSICAL EXAMINATION
V/S:
SKIN
HEENT:
C/L:
CVS:
ABD:
FH:___
FHT:____
L1:
L2:
L3:
L4:
U/A
FBS
UTZ
Pregnancy Uterine,
Age of Gestation
In labor or Not in Labor
Complications
G_P_(_ _ _ _)
P:
1.
2.
3.
4.
Work-up
Medications
Instructions
To come back on:
RESIDENTS UNDER YOUR TEAM/
DR/DR/DR/SC_____
OPD SOAP SAMPLE

O:
BP:
AOG:
100/60 mmhg
38 wks
LMP: Aug 5, 2011

EDC: May 12, 2012
PHYSICAL EXAMINATION
V/S: BP OF 100/ 60 mmhg
PR of 80 bpm
RR of 17 cpm
SKIN: dry, warm, good turgor
HEENT: anicteric sclera, pinkish palperbral
conjuctivae
C/L: equal chest expansion, clear breath
sounds
CVS:adynamic precordium, normal rate
and regual rhythm, no murmurs
ABD: ovoid
FH:32cm
FHT:145 bpm
L1:breech
L2:fetal back at right maternal side;
fetal small parts at left maternal side
L3:cephalic, not engaged
L4:positive
S:
PAST MEDICAL HISTORY
(- ) HPN
disorders
(-) DM
drug allergies
(-) Asthma
and Minor Operations
(-) Cardiovascular disorders
FAMILY HISTORY
(+) HPN, paternal
)Thyroid disorders
(-) DM
Cancer, maternal
(-) Asthma
Multi-fetal Preganacies
(-) Cardiovascular disorders
(-)Thyroid
(-) Food and
(-) Major
((-)
()
INTERNAL EXAMINATION: closed, smooth,

no masses
NOTE: On IE, if open: make sure you
include the following: (with examples)
A. Cervical dilatation 2cm
B. Effacement 50%
C. Station - (- 3)
D. Presentation- cephalic
E. Bag of water- Intact
PERSONAL AND SOCIAL HISTORY

Patient is a college gradute, currently
unemployed, single, living in for 6 years to
a 29 year old government employee
She is a non-smoker, non-alcoholic
beverage dinker and denied the use of
illicit drugs
GYNECOLOGIC HISTORY
M: 13
I: regular monthly intervals
Duration: 3days
Amount: moderate flown. 3 pads per day
Symptoms: (-) dysmenorrheal
Coitarche: 21
# of Sexual Partners: 2
Family Planning Method: OCPs for 7 years,
IUD for 1 year, DMPA for 3 months
OB HISTORY
G2P1(1001)
G1-2008- delivered at local health center
assisted by midwives, full term, via NSD,
BW of 2.8 kg, no fetomaternal
complications
G2-present pregnancy
GUT: no profuse vaginal bleeding

EXT: good peripheral pulses, no edema
A:
Pregnancy Uterine, 38 weeks
, Not in Labor, G2P1(1001)
P:
1.
2.
3.
Work-up
CBC with PC
BT
HbsAg
U/A
FBS
UTZ, TAS
Multivitamins + FeSo4, 1 cap OD
Increase oral fluid intake
6
4.
5.
6.
7.
8.
Drink 2 glasses of milk perday

Monitor Fetal Kicks
Watch out for danger signs of pregnancy
Left lateral decubitus
To come back after 1 week (state the date)
DR DUMALAGAN/SARMENMESO/AMORTIZADO/MACARAMBON
SC CHURVA
ADDITIONAL INFO
st
1. FBS: ordered on 1 prenatal check-up: based
on CPG
2. TVS, UTZ for below 12 weeks AOG
TAS, UTZ for 12 weeks and above
3. Leopolds Maneuver: for 32 weeks and above
4. Internal Exam: for 37 weeks and above patients
5. Folic Acid: given to patients 10 weeks AOG and
below
6. Monitor fetal kicks: Advised to patients 28
weeks and above
Note: for SCs under DR. DUMALAGANs team, OB
HISTORY is should be written first in the S part.

OB History Endorsement Format

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ENDORSEMENT FORMAT

Endorsing a case of ______. , __ __ years old, Gravida

Skin of px is warm and of good turgor.

] No history of previous hospitalizations.

Cardiovascular: adynamic precordium, distinct heart

] No known food and drug allergies.

] Denies medical illnesses.

For the family history

ovoid w/ fundic height of _____cm

Fetal heart tone of _____beats per minute w/ uterine

For the gynecologic history

For the Obstetric history

For the history of present pregnancy

Preoperative Diagnosis of:

Intraoperative findings of:

OPD SOAP FORMAT

OPD SOAP SAMPLE

LMP: Aug 5, 2011

INTERNAL EXAMINATION: closed, smooth,

PERSONAL AND SOCIAL HISTORY

GUT: no profuse vaginal bleeding

Drink 2 glasses of milk perday

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Endorsing a case of __. , years old, Gravida