A postpartum visit note documents a patient's recovery after delivery across four domains: physical healing, mental health, reproductive planning, and infant feeding, plus the piece most notes skip entirely: what this pregnancy means for the patient's long-term health. A good template walks you through all five in the order the visit actually unfolds.

Below you'll find a free, downloadable postpartum visit note template, a completed worked example, a breakdown of the three postpartum visit types, and a step-by-step guide to writing notes that hold up clinically, for billing, and for the handoff to ongoing care.

Quick download: Grab the free Postpartum Visit Note template here.

Key Takeaways

• Postpartum care is a process, not one appointment: ACOG recommends contact within three weeks of delivery and a comprehensive visit no later than twelve weeks. Your note should mark which visit type it documents: initial contact, interim, or comprehensive.
  
  

• Name the screening instrument and record the score: "Mood: normal" is not a mental health screen. "EPDS 6, item 10 negative" is. A named instrument with a documented score and self-harm item is the minimum standard.
  
  

• The long-term risk handoff is the section that matters most: A hypertensive disorder, gestational diabetes, or preterm birth changes a patient's lifetime cardiovascular and metabolic risk. Document that you discussed it and who owns follow-up.
  
  

• A structured template cuts what gets missed: Postpartum visits cover more ground in 20 minutes than almost any other encounter. A prompted template, or an AI scribe that drafts the note for you, keeps the note complete without pulling you away from the patient.
  
  

What Is a Postpartum Visit Note?

A postpartum visit note is the clinical record of a follow-up encounter after delivery, typically written by an OB-GYN, midwife, or family physician during the first twelve weeks postpartum. It captures the interval history since delivery, physical recovery, mood and well-being screening, contraception counseling, infant feeding status, and the plan for transitioning the patient back to ongoing primary care.

Think of it as the bridge document between two phases of a patient's life. The delivery record tells the story of the birth; the postpartum note tells the story of the recovery, and flags anything from the pregnancy that the patient's future clinicians need to know about.

The shift that reshaped this note came in 2018, when ACOG reframed the "six-week checkup" as ongoing fourth-trimester care. One appointment at six weeks misses the window when most complications, mood disorders, and feeding problems actually surface. Your documentation should reflect that new structure.

The Three Postpartum Visit Types

Before writing anything else, mark which visit this is. The visit type determines what the note needs to cover.

Patients with a hypertensive disorder of pregnancy need a blood pressure check even sooner: within 7 to 10 days of delivery, or within 72 hours for severe hypertension. If that applies, the note should show it happened.

What to Include in a Postpartum Visit Note

There's no single mandated format, but complete postpartum notes consistently cover the same eight sections. Our free template is organized around them:

• Visit context: Visit type (initial/interim/comprehensive), delivery date, weeks postpartum, delivery mode (vaginal, operative vaginal, cesarean), and any pregnancy or delivery complications.
  
  

• Interval history: Bleeding pattern and lochia, pain, urinary and bowel function, incontinence, sleep, return of intercourse and any dyspareunia.
  
  

• Physical exam: Vitals (especially BP), breasts, abdomen and any incision, perineum or cesarean wound healing, uterine involution, pelvic floor assessment.
  
  

• Mood and well-being: Named screening instrument (EPDS or PHQ-9), the score, the self-harm item result, social support, and intimate partner safety when indicated.
  
  

• Infant feeding: Feeding method, latch or supply issues, nipple pain, mastitis signs, and the patient's feeding goals.
  
  

• Reproductive planning and contraception: Pregnancy intentions, interpregnancy interval counseling, method chosen or declined, and breastfeeding compatibility.
  
  

• Long-term risk handoff: Whether complications like preeclampsia, gestational diabetes, or preterm birth were discussed as lifetime risk factors, what follow-up testing was ordered (e.g., glucose tolerance testing after GDM), and which clinician owns ongoing care.
  
  

• Plan and disposition: Return-to-activity and return-to-work guidance, referrals (pelvic floor PT, lactation, behavioral health), and next visit or transition to primary care.
  
  

This is where a template earns its keep. A blank note field invites "doing well, no concerns." A prompted field asks you for the EPDS score, the incision check, and the GDM follow-up lab before the patient has left the room.

Pro tip: Write the long-term risk section as if it's addressed to the patient's primary care physician five years from now, because it effectively is. "Preeclampsia this pregnancy; counseled on elevated lifetime cardiovascular risk; annual BP and metabolic screening recommended; transitioned to Dr. Patel" is the sentence that changes outcomes.

Postpartum Visit Note Example

Here's a completed comprehensive-visit note using the template structure. (All patient details are fictitious.)

VISIT CONTEXT

• Comprehensive postpartum visit. Delivery 10/14, now 6 weeks 2 days postpartum. Primary low transverse cesarean for arrest of dilation at 39+3. Pregnancy complicated by gestational diabetes (diet-controlled).

INTERVAL HISTORY

• Lochia resolved week 4. Incisional pain resolved; no drainage or opening. Mild stress incontinence with coughing, improving. Sleeping in 3–4 hour stretches. Has not resumed intercourse. Voiding and bowel function normal.

EXAM

• BP 118/74, HR 72, BMI 29.1. Breasts soft, no erythema or masses. Abdomen soft; Pfannenstiel incision well healed, no induration. Uterus involuted, nontender. Perineum intact. Pelvic floor tone mildly reduced.

MOOD & WELL-BEING

• EPDS 5. Item 10 (self-harm) negative. Reports good support from partner and mother. Screens negative for IPV.

INFANT FEEDING

• Exclusively breastfeeding. Latch improved after lactation consult at week 2. No current nipple pain or mastitis symptoms. Goal: continue to 6 months.

CONTRACEPTION

• Desires 2–3 year interpregnancy interval. Counseled on options compatible with breastfeeding. Chose levonorgestrel IUD; placed today without complication.

LONG-TERM RISK & TRANSITION

• GDM this pregnancy: 75 g 2-hour OGTT ordered today (4–12 week window). Counseled on elevated lifetime type 2 diabetes risk; recommended screening every 1–3 years. Records and summary sent to PCP, who assumes ongoing care.

PLAN

• Pelvic floor PT referral for stress incontinence. Cleared for graded return to exercise. Return to work 11/25 as planned. Follow up PRN; OGTT results to patient and PCP.

Notice what makes this note work: every domain has a finding, every finding has a disposition, and the pregnancy complication has a named test, a named risk conversation, and a named receiving clinician.

How to Write a Strong Postpartum Visit Note: Step by Step

A template gives you the structure. These five habits turn it into documentation that actually protects patients.

1. Anchor the note to weeks postpartum and visit type

"Postpartum visit" tells a reviewer nothing. "Comprehensive visit at 6 weeks 2 days after primary cesarean" frames every finding that follows. Timing determines what's normal: lochia at 2 weeks is expected; at 8 weeks it's a finding.

2. Screen mood with an instrument, not an impression

Perinatal mood and anxiety disorders are the most common complication of childbearing, and they're routinely missed when screening is conversational. Document the tool (EPDS or PHQ-9), the numeric score, and, always, the self-harm item result. If the score is positive, the note needs a plan: referral, safety assessment, and follow-up interval.

3. Tie every complication to a follow-up action

Gestational diabetes without an ordered OGTT is an open loop. A hypertensive disorder without a documented BP recheck plan is an open loop. The pattern is always the same: complication → test or referral → who receives the result. Close all three in the note.

4. Document contraception counseling even when the answer is no

Counseling on interpregnancy interval and contraceptive options is part of the comprehensive visit whether or not the patient chooses a method. "Counseled on options; patient declines contraception at this time, understands return-to-fertility timing" is a complete entry. A blank contraception field is not.

5. Write the transition of care explicitly

The comprehensive visit is supposed to end with a handoff to ongoing care. Name the receiving clinician, list what was sent, and state which risks they're inheriting. This is also where a structured note format pays off downstream: clean, consistently structured documentation is what makes the handoff readable on the other end.

Bottom line: A strong postpartum note is a set of closed loops. Every screen has a score, every complication has a test, every risk has an owner.

Common Postpartum Note Mistakes to Avoid

Even experienced clinicians fall into the same traps, especially when the visit runs long and the note gets written at the end of clinic.

• "Mood: normal" with no instrument. Fix it by recording the tool, score, and self-harm item every time, normal results included.
  
  

• No mention of pregnancy complications. The postpartum note should restate them and connect them to follow-up, even if they resolved at delivery.
  
  

• Missing the GDM glucose tolerance test. Order it in the 4–12 week window and document where results go. This is one of the most frequently dropped follow-ups in all of obstetrics.
  
  

• Contraception section left blank. Document counseling and the patient's decision, whatever it is.
  
  

• No care transition. A note that ends with "follow up PRN" leaves the patient's long-term risks with nobody. End with a named clinician and a sent summary.
  
  

A Quick Word on Billing

Postpartum documentation lives inside a billing tension worth knowing. ACOG defines postpartum care as extending to twelve weeks, but most payers still define the postpartum period as six weeks from delivery, bundled into the global obstetric package.

Practically, that means:

• Routine postpartum visits and contraception counseling are bundled into the global OB fee, not separately billable.
  
  

• Evaluation of a genuine complication is separately reportable. A visit driven by postpartum hypertension, a wound infection, or a positive depression screen with treatment initiated is distinct from routine global care, and your note is the evidence. This is where thorough documentation directly supports accurate coding and reimbursement.
  
  

• CPT 59430 is the postpartum-care-only code, used when your practice provided postpartum care but not the delivery.
  
  

The rule of thumb: if the visit did more than routine recovery care, the note has to show it, or the work disappears at billing.

Hands-Free Postpartum Notes with Sully.ai

A template solves the structure problem. It doesn't solve the time problem: a comprehensive postpartum visit covers four clinical domains, a procedure like IUD placement, and a risk-counseling conversation, and the note usually gets written from memory after the patient leaves.

This is where an AI medical scribe changes the workflow. With Sully.ai, you start the scribe at the beginning of the encounter and let ambient AI capture the visit as it happens. By the time the patient is dressed, a structured postpartum note is ready for your review, formatted to this exact template with the EPDS score, the contraception decision, and the risk-counseling language already in place.

The downstream benefits stack:

• Nothing gets dropped. The template's prompted fields are filled from the actual conversation, not reconstructed later.
  
  

• The risk handoff gets written. The counseling you did out loud becomes the documentation your patient's PCP will read.
  
  

• You finish notes in clinic, not at home.
  
  

Sully.ai is built for healthcare from the ground up and meets HIPAA standards for handling protected health information. The scribe works alongside a broader team of AI employees (coder, receptionist, and more) designed to take documentation off clinicians' plates.

Frequently Asked Questions

What should be included in a postpartum visit note?

A complete postpartum note includes the visit type and weeks postpartum, delivery mode and complications, interval history, physical exam with blood pressure, a mood screen with a named instrument and score, infant feeding status, contraception counseling and decision, follow-up on pregnancy complications, and an explicit transition-of-care plan.

When should the postpartum visit happen?

ACOG recommends contact with all patients within three weeks of delivery and a comprehensive postpartum visit no later than twelve weeks. Patients with hypertensive disorders of pregnancy need a blood pressure check within 7–10 days, or within 72 hours after severe hypertension.

What screening tools are used at the postpartum visit?

The Edinburgh Postnatal Depression Scale (EPDS) is the most widely used postpartum mood screen; the PHQ-9 is a common alternative. Document the instrument name, the numeric score, and the self-harm item result, and pair any positive screen with a documented follow-up plan.

Is the postpartum visit billed separately?

Usually not. Routine postpartum care is bundled into the global obstetric package, which most payers define as six weeks from delivery. Evaluation and management of a true complication is separately reportable, and CPT 59430 covers postpartum care when your practice didn't perform the delivery.

How is a postpartum note different after a cesarean?

The structure is the same, but the exam section adds incision assessment (healing, drainage, induration), and the plan typically addresses lifting restrictions and a longer graded return to activity. Complication follow-up and mood screening are identical regardless of delivery mode.

Can I create my own postpartum visit note template?

Yes. Start from the free template above, then adapt the prompts to your practice's protocols and EHR. Once the structure is set, an AI scribe can generate every postpartum note in that exact format automatically.

This template is provided for documentation reference only. Adapt it to your practice's protocols and current clinical guidelines. It does not replace clinical judgment.

This article is for general informational purposes and is not legal or medical advice. Confirm that any form you use meets applicable regulations, including HIPAA, and consult your compliance team before deploying it.