GBS: NEG / POS

_____________________

NAME

RUBELLA:

BABY:

POSTPARTUM

IMM / NON

MALE

/ FEMALE

DATE: ____________________
ADMIT TIME: ______________
PROVIDER:________________
G_________P_________
T

P

A

NEG / POS

NAME:

U/S: _______-________-_____
GEST:________________

C/O______________________

VDRL:

NEG / POS

TIME OF DELIVERY:

HIV:

NEG / POS

LAC:

BLOOD:

A

O

+
FOLEY:

Y

NKA / ALLERGIES: ____________

BREAST

BLOOD:

FEEDING? Y

/ N IV: L _____ /R_____

CONTRACTIONS:

______________PIT @__________

TIME:

IV MED/ EPIDURAL:

_________ RATE:________cc/h

BTL:

Y

MARITAL:

/

S W D M_______________

ADV.DIR/WILL

q ______________
_________

_______________________

RR_______HR _______ %_____

T_______ BP _______/_______
PAIN: 1 2 3 4 5 6 7 8 9 10
AGE:

CONSENT Y / N

N

WORK: NONE/_____________________

/ MOD/ STRONG

_______ HT:_______’________”

B AB
+

MEDS: ______________________

BREAST/ BOTTLE /BOTH
TIME BEGAN:

A O

Y

/N

WANT? Y

/N

--

NEED RHOGAM: Y / N

PEE:

RUBELLA:

HEP B: Y / N

IMM / NON

NEG / POS

BLOOD:

VDRL:

NEG / POS

HIV:

NEG / POS

A O

COOMBS:

IV: L _________ /R_________

NEG

Y

/N

B AB
+

--

/ POS

PKU: Y / N

ABUSE/THREAT? Y / N FINANCIAL? Y/N
HOUSE/
REL.

APT/

MOBILE HOME

PREF: NONE/__________________

CHILDBIRTH

CLASS: Y

/N

SMOKE__________/ ETOH/ DRUGS

FLUID_______RATE_________
RR_______HR _______ %_____

/ WATCH:

__________________________

PAIN: 1 2 3 4 5 6 7 8 9 10

__________________________

MEDS:___________________

__________________________

GIRL / BOY -NAME_________________

NOTES/ ORDERS / LABS/ DC TX:

ABNORMALITIES/ PROBLEMS

T_______ BP _______/_______

__________________________
__________________________

VOIDING: Y

FOLEY Y / N

HOME MEDS: PNV/_____________

UP TO BATHROOM:

ILLNESS/ HX

REG

/N

/ CLEARS

GIFT:

BLACK

/N

Y

/N

ATE YET? Y

BLUE FOLDER:
0 1 2 (3 SWOLLEN) 4
URINE DIPSTICK: 0 TR 1 2 3 4
HA: Y / N PAIN #__________
EPIGASTRIC PAIN: Y / N #____
REFLEXES: 0 1 2 3 4
CLONUS: Y / N
PLATELETS

POOP:

HEP B:

_____________________________

EDEMA:

/N

HEARING TEST: Y / N

Y

/ FAMILY HX:

Y

GBS: NEG / POS

HAD EPIDURAL?

NKA / ALLERGIES: ____________,

/N

__________________________

WT. NOW_________ PRE__________
LAST FOOD ______ DRINK________

/ BOTTLE / BOTH

FLUID__________RATE_________

PEDI: _____________________

CLEAR/ MEC/ ODOR:

FHT’S:

________/_________

-

NATURAL/

COLOR/ AMT:

APGARS:

GESTATION:_____DUBOWITZ:____

MEMBRANES:
INTACT / RUPTURED: __________

BLEED: Y/ N

0 1 2 3 4

PEDI: _____________________

FUNDUS ___________________

_____________________________

FREQUENCY

_________

WT:_______LBS_______OZ

B AB

SVE:________/________/_______

MILD

____________________

L

LMP: ______-________-_____

WKS

HEP B:

Y

/N

/ WHITE BAG

/N

NOTES/ ORDERS / LABS/ DC TX:

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