Location: Erwin Rd, 4th floor — park in the lot on the 4th level where clinic is (will get towed if you park below). First patient 12:40 PM.
- •Get to HROB by 12:10 PM on first day — get oriented to clinic + MAs.
- •You’ll have your own patients assigned to you, ~10 max.
EPIC Context: Duke Perinatal Durham Clinic
Dot phrases: .mfmmasterlist (select postpartum) and .hrobppplans
Prechart! Discharge summary review + use that info to template your note. Note problems, birth control preference, HTN disease (BP follow-up, on meds?, taking at home?), PCP follow-up (if not, send primary care referral).
Workflow:
- •Stop at front desk to be let into the back workroom.
- •You’ll be with the Outpatient resident and 1 attending preceptor; 1 MA assigned for the afternoon.
- •Let MA know if contraception known in advance, fetal death (ask to room far away from seeing lots of babies).
- •MA will give you vitals, name of pt, any concerns before seeing patient.
- •Pay extra attention to BP, especially if HTN disease.
- •Write down GsPs, when delivered, modality, comorbidities needing follow-up (gDM with med or pre-gDM, HTN disorder, 3-day BP appt), sub-specialist follow-up, PP bleeding or depression, contraception.
- •Julia Tarr (social work) is on site for mental health.
- •Mostly work with MAs and nursing assistants — communicate everything you need (meds, orders, tests, labs, contraception).
- •Attending doesn’t have patients — you have your own panel. Present for all procedures. Route all notes to attending on “Wrap Up” tab. Stay until finish notes ideally, but can finish from home.
Documentation / Appointment Talking Points:
- •Summarize labor course, IOL, complications, PP hemorrhage, vaginal laceration, STAT C/S, baby that died (highlight red/bold), baby in NCU (highlight in yellow). Get it from discharge summary.
- •Follow up with patients on traumatic, difficult events.
- •Note medications continued/discontinued + impact on breastfeeding (Lactmed.com).
- •Wound vac, etc. that needs changing or evaluation.
- •PP contraception: given before discharge or not? Counsel that not using contraception = increased risk of uterine rupture in first 18 mo and increased risk of preterm birth.
- •Confirm if patients want bridge contraception until ultimate management (vasectomy etc.). May need UPT if getting BC.
- •Still on anticoagulation? Stopped prematurely? Explain why anticoag important.
- •Follow up with PCP / sub-specialists.
Exams:
- •C/S: no vaginal exam, examine scar.
- •SVD: offer vaginal exam if laceration → ask attending to join to evaluate.
- ◦Up to 2nd degree: don’t need to look at it.
- ◦2nd degree bothering them: look at it.
- ◦Greater than 2nd: should evaluate.
- •Post-placental IUD: string check, bedside U/S if don’t see strings.
Review the Bs: Baby (bonding), Belly (pain, C/S scar), Breasts, Blues, Bleeding (still bleeding? return of menses?), Bladder (urinary sx), Boot knocking (intimacy with partner? — don’t have sex if laceration not healed, normalize they may not want to have sex right now).
Responsible for In Basket — call/message patients back with results, answer questions.
Pearls:
- •Look up breastfeeding interactions with meds and any unfamiliar morbidities.
- •In-person Spanish interpreter: Ana.
- •For fetal death, still review milestones — sex, period resumed, expelling clots.
- •Depression screen (EDPS) → if above 10 or SI positive, dig into mood. If blue ribbon, no EDPS. Julia Tarr is social worker.
- •Tearful patient → stabilize: let them know we’d like to continue the conversation and have resources to help after the visit.
- •No contraception for self-pay → give them info to Health Department for LARC at sliding scale. Warn them even Pap smear is $200.