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Discharge Summary Susan was subsequently discharged 3 days after admission by her attending physician, Dr. Martinez. LOCATION: Inpatient, Hospital PATIENT: Susan Hillard ATTENDING PHYSICIAN: Andy Martinez, MD SUMMARY OF HOSPITALIZATION:The patient was admitted with a history of 37 weeks’ pregnancy. She was having some leaking membranes and some contractions. The patient was stable on admission. She had a spontaneous vaginal delivery 3 days ago. Both baby and mother were healthy. On postnatal day 1, the patient had a tubal ligation done by Dr. Sanchez. The postoperative and postpartum period was uneventful. The patient was stable. Vital signs: Temperature 36Ëš C, pulse 72, respirations 20, blood pressure 105/72. The patient was discharged today. DISCHARGE INSTRUCTIONS:Activity level: Pelvic rest for 6 weeks; no heavy weight lifting for 6 weeks. Diet: Regular. MEDICATIONS:Pain control medication p.r.n. (as needed) FOLLOW-UP in 6 weeks. CONDITION ON DISCHARGE:Patient’s condition was improved. Bleeding and pain were minimal. Vital signs were stable. DISCHARGE DIAGNOSIS:Postpartum day 2 with postoperative tubal ligation day 1. SERVICE CODE(S): ICD-10-CM DX CODE(S):

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