NAME: T

DATE: TIME:

BP HR

/ %

COMPLICATIONS:
LABS:
PLATELETS:

SOCIAL HX:
WORK: NONE/ ADV.DIR/WILL Y

RR

PROVIDER:

PAIN:

0 1 2 3 4 5 6 7 8 9 10

IV:

LT

/ RT

FOLEY: Y

/

N

/N

WANT? Y

/N /
N

G
T
LMP: U/S:

P
P

REPEAT C/S: Y / N
A L

MEDS:
WT. NOW PRE

MEDS:

PIT @
DUE

mU/min

ABUSE? Y HOUSE/

/N
APT/

FINANCIAL? Y MOBILE HOME

AMP X
MAG: BOLUS MAINTAIN

@
STADOL
EPIDURAL: PLACED BY:

/ /

/ /

LAST FOOD
NKA

DRINK

g g/h / EPIDURAL

@

REL. PREF: NONE/

/ ALLERGIES:

NATURAL /IV MED

mL/h

CHILDBIRTH CLASS: Y SMOKE:

/N / DAY

WKS GEST: C/O:
HOME MEDS: ILLNESS/ HX/ FAMILY HX:

PEDIATRICIAN:
RISKS:
GBS PROLONGED ROM PRE/ POSTMATURE FEVER/ CHORIO PIH/ MAG BS STD COOMBS DIABETES MALPRES DYSTOCIA APGAR WT GENETIC/ CHRONIC DISEASE PROLAPSE BLEED SMOKE/ DRUGS ANOMALIES OLIGO/ POLY

C OR PK ETOH:

CAFF:

DRUGS:

SVE: INTACT / RUP’D:

/
SROM

/
/ AROM @

NONREASSURING

MARITAL: S W D M:

BREAST
HX SURGERY

/

BOTTLE

/ BOTH

BTL: Y / N CONSENT

Y

/N

GIRL

/ BOY  NAME:

CLEAR/ MEC/ ODOR:
CONTRACTIONS:
FREQUENCY Q: MIN.

/ ANESTHESIA:
NEG

NOTES:

PIH:
URINE PROTEIN

GBS:
RUBELLA

/ POS / POS / POS / POS + -COMPLICATIONS:

: 0

TR

1 2 3 4
Y

:

IMM /NON NEG NEG NEG A

BTL: Y / N CONSENT
HA: Y

/N

TIME BEGAN: MILD/ MOD/ STRONG TONE: SOFT/

HEP B: VDRL: HIV: BLOOD:

/N

PAIN

# /N #

EPIGASTRIC PAIN: Y REFLEXES:

0 1 2 3 4
Y

FHT’S:
BLEED: Y

O AB B

VISUAL PROB?
CLONUS: Y

/

N
OUTPUT:

/N

COLOR/AMT:

/N

NAME: T
DATE: TIME:

BP HR

/ %

SOCIAL HX:
PLATELETS:
WORK: NONE/ ADV.DIR/WILL Y

RR

LABS:

PROVIDER:

PAIN:

0 1 2 3 4 5 6 7 8 9 10

IV:

LT

/ RT

FOLEY: Y

/

N

/N

WANT? Y

/N /
N

G
T
LMP: U/S:

P
P

REPEAT C/S: Y / N
A L

MEDS:
WT. NOW PRE

MEDS:

PIT @
DUE

mU/min

ABUSE? Y HOUSE/

/N
APT/

FINANCIAL? Y MOBILE HOME

AMP X
MAG: BOLUS MAINTAIN

@
STADOL
EPIDURAL: PLACED BY:

/ /

/ /

LAST FOOD
NKA

DRINK

g g/h / EPIDURAL

@

REL. PREF: NONE/

/ ALLERGIES:

NATURAL /IV MED

mL/h

CHILDBIRTH CLASS: Y SMOKE:

/N / DAY

WKS GEST: C/O:
HOME MEDS: ILLNESS/ HX/ FAMILY HX:

PEDIATICIAN:
RISKS:
GBS PROLONGED ROM PRE/ POSTMATURE FEVER/ CHORIO PIH/ MAG BS STD COOMBS DIABETES MALPRES DYSTOCIA APGAR WT GENETIC/ CHRONIC DISEASE PROLAPSE BLEED SMOKE/ DRUGS ANOMALIES OLIGO/ POLY

C OR PK ETOH:

CAFF:

DRUGS:

SVE: INTACT / RUP’D:

/
SROM

/
/ AROM @

NONREASSURING

MARITAL: S W D M:

BREAST
HX SURGERY

/

BOTTLE

/ BOTH

BTL: Y / N CONSENT

Y

/N

GIRL

/ BOY  NAME:

CLEAR/ MEC/ ODOR:
CONTRACTIONS:
FREQUENCY Q: MIN.

/ ANESTHESIA:
NEG

NOTES:

PIH:
URINE PROTEIN

GBS:
RUBELLA

/ POS / POS / POS / POS

: 0

TR

1 2 3 4
Y

:

IMM /NON NEG NEG NEG A

BTL: Y / N CONSENT
HA: Y

/N

TIME BEGAN: MILD/ MOD/ STRONG TONE: SOFT/

HEP B: VDRL: HIV: BLOOD:

/N

PAIN

# /N #

EPIGASTRIC PAIN: Y REFLEXES:

0 1 2 3 4
Y

FHT’S:

O AB B

VISUAL PROB?

/

N

BLEED: Y /N COLOR/AMT: + -- CLONUS: Y /N OUTPUT: .

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