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DATE: TIME:
T RR
BP HR
/ %
COMPLICATIONS:
LABS:
PLATELETS :
SOCIAL HX:
WORK: NONE/ ADV.DIR/WILL Y
PROVIDER:
PAIN:
0 1 2 3 4 5 6 7 8 9 10
IV:
LT
/ RT
FOLEY: Y
/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/
AMP X
MAG: BOLUS MAINTAIN
@
STADOL
EPIDURAL: PLACED BY:
/ /
/ /
LAST FOOD
NKA
DRINK
g g/h / EPIDURAL
/ ALLERGIES:
mL/h
/N / DAY
PEDIATRICIAN:
RISKS:
GBS PROLONGED ROM PRE/ POSTMATURE FEVER/ CHORIO PIH/ MAG BS STD COOMBS Y DIABETES MALPRES DYSTOCIA APGAR WT GENETIC/ CHRONIC DISEASE PROLAPSE BLEED SMOKE/ DRUGS ANOMALIES OLIGO/ POLY
C OR PK ETOH:
CAFF:
DRUGS:
/
SROM
/
/ AROM @
NONREASSURING
MARITAL: S W D M:
BREAST
HX SURGERY
BOTTLE
/ BOTH
BTL: Y / N CONSENT
/N
GIRL
/ BOY NAME:
/ ANESTHESIA:
NEG
NOTES:
PIH:
URINE PROTEIN
GBS:
RUBELLA
: 0
TR
1 2 3 4
Y
BTL: Y / N CONSENT
HA: Y
/N
/N
PAIN
# /N #
0 1 2 3 4
Y
FHTS:
BLEED: Y
O AB B
VISUAL PROB?
CLONUS: Y
N
OUTPUT:
/N
COLOR/AMT:
/N
NAME:
DATE: TIME:
T RR
BP HR
/ %
COMPLICATIONS:
LABS:
PLATELETS:
SOCIAL HX:
WORK: NONE/ ADV.DIR/WILL Y
PROVIDER:
PAIN:
0 1 2 3 4 5 6 7 8 9 10
IV:
LT
/ RT
FOLEY: Y
/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/
AMP X
MAG: BOLUS MAINTAIN
@
STADOL
EPIDURAL: PLACED BY:
/ /
/ /
LAST FOOD
NKA
DRINK
g g/h / EPIDURAL
/ ALLERGIES:
mL/h
/N / DAY
PEDIATICIAN:
RISKS:
GBS PROLONGED ROM PRE/ POSTMATURE FEVER/ CHORIO PIH/ MAG BS STD COOMBS Y DIABETES MALPRES DYSTOCIA APGAR WT GENETIC/ CHRONIC DISEASE PROLAPSE BLEED SMOKE/ DRUGS ANOMALIES OLIGO/ POLY
C OR PK ETOH:
CAFF:
DRUGS:
/
SROM
/
/ AROM @
NONREASSURING
MARITAL: S W D M:
BREAST
HX SURGERY
BOTTLE
/ BOTH
BTL: Y / N CONSENT
/N
GIRL
/ BOY NAME:
/ ANESTHESIA:
NEG
NOTES:
PIH:
URINE PROTEIN
GBS:
RUBELLA
: 0
TR
1 2 3 4
Y
BTL: Y / N CONSENT
HA: Y
/N
/N
PAIN
# /N #
0 1 2 3 4
Y
FHTS:
BLEED: Y
O AB B
VISUAL PROB?
CLONUS: Y
N
OUTPUT:
/N
COLOR/AMT:
/N