Progress Notes
Page 1
1/3/20 S: Complains of more pain, wants relief
03 O: Cervix 5 cm dilated, completely effaced,
0900 0 station
BOW bulging
EFM shows Ctx Q3 x 60, reactive with
good short and long-term variability on
external tracing, baseline 150
A: Active phase labor with satisfactory
progress
P: CLE.
Anesthesia notified
Attending OB notified.
Mike Hughey, MD
PG-1
1/3/20 S: C/O gush of fluid
03 Comfortable with CLE
1100 O: Cervix 8 cm/C/+1
Membranes grossly ruptured. Nitrazine
positive.
EFM: Baseline 150, no decels., Ctx Q 2 ½
to 3. Good long-term variability
A: SROM
Active Phase labor with good progress
P: OB attending notified
Mike Hughey, MD
Note: These Progress Notes are for illustrative purposes only. Remember that:
1. Not all patients will present in this fashion.
2. Local customs may require significant modification of the Progress Note format and content.
Progress Notes
Page 2
PG-1
1/3/20 S: C/O rectal pressure
03 Still comfortable with CLE
1200 O: Cervix C/C/+4 (head visible with
separation of labia)
EFM: Unchanged except for mild variable
decels with each contraction
A: 2nd Stage Labor
P: Begin pushing
OB attending here
Mike Hughey, MD
PG-1
Note: These Progress Notes are for illustrative purposes only. Remember that:
1. Not all patients will present in this fashion.
2. Local customs may require significant modification of the Progress Note format and content.