Postpartum Care Focused Exam Checklist
Document key findings and interventions for a focused postpartum care exam visit.
Patient Name
*
First Name
Last Name
Date of Visit
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Vital Signs Reviewed
Blood Pressure
Pulse
Temperature
Respiratory Rate
Physical Exam Findings
Uterus involuted
Lochia normal
Perineum healing
Breasts/nipples healthy
Other (specify below)
Mood and Mental Health Screening
Normal
Signs of depression/anxiety
Referral needed
Breastfeeding Status
Exclusively breastfeeding
Mixed feeding
Formula feeding
Not applicable
Contraception Counseling Provided
Yes
No
Declined
Complications or Concerns Identified
Infection
Excessive bleeding
Pain
None
Other (specify below)
Follow-up Plan / Referrals
Clinician Notes
Submit
Should be Empty: