7 am 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
8 am
10
am With wound dressing dry; With mild post operative pain as claimed
12

With slight lochia rubra

nn

BP = 140/100 mmHg; T=38.4 C; Tepid sponge bath done for 15 minutes & cold

2 pm compress placed over the forehead

3 pm 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

Time
7 am

Received with an IVF of D5 LRS 1 L + 10 units of oxytocin on

around 300 cc & regulated at 42 gtts/min; consumed and removed
@ 11 am

9 am
10 am

With slight lochia rubra

10:30 am

BP = 130/80 mmHg

12 nn

Visited by Dra. ________ with orders

3 pm

Initial breastfeeding done / Breastfed her baby as demand

Consumed a bowl of rice gruel & 200mL of water
Sponge bath and perineal care done
Endorsed for continuity of care