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AUDIT REPORT T11.2 DISCHARGE SUMMARY LOCATION: Inpatient, Hospital PATIENT: Lisa Logan ATTENDING PHYSICIAN: Andy Martinez, MD DIAGNOSIS: 1. Spontaneous rupture of the membranes. 2. Failure to progress. 3. Intrauterine pregnancy 38 weeks’ gestation, delivered. PRINCIPLE PROCEDURE: Primary low transverse Cesarean section. INDICATION: The patient is a 22-year-old gravida 1 who underwent spontaneous rupture of membranes and presented to her primary obstetrician. She developed intermittent repetitive late decelerations and was transferred to our facility for lack of cesarean coverage where she was originally admitted. On a low dose of Pitocin, the baby had reactive tracing, but when Pitocin was increased because she was not progressing in labor, the baby, again, began to develop repetitive variables, and she was offered cesarean section for delivery of the infant. She underwent Cesarean section of a viable 5 pound 13.7 ounce infant with Apgars of 7 at 1 minute and 9 at 9 minutes with the cord around the neck times one and she returned to recovery in stable condition. By later on postoperatively day zero, she was ambulating with active bowel sounds. She was passing flatus by postoperative day one and tolerating a regular diet. She remained afebrile with stable vital signs. She continued to do well, and by postoperative day two, she requested discharge. DISPOSITION: Discharge to home. CONDITION AT DISCHARGE: Good. FOLLOW-UP with her primary OB physician for staple removal and postoperative care. DISCHARGE MEDICATIONS:  1. Percocet 5/325 mg 1-2 p.o. q.4h. p.r.n.  2. Ibuprofen 600 mg 1 p.o. q.6h. p.r.n, dispense 30 with no refills.  3. Iron sulfate 1 p.o. b.i.d., take with food. DISCHARGE HEMOGLOBIN: 9.5. PATHOLOGY: No pathologic diagnosis. T11.2: SERVICE CODE(S): 99239______________________________ ICD-10-CM DX CODE(S): O42.92, O62.0, Z37.0__________________ INCORRECT/MISSING CODE(S): ____________________________

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