Room: _______ Name: ______________________ Age: _____ BMI: _____
☐Report Note
OB: _________ Allergies: ____________________________ G/P: ____ /____
☐Immunizations
Vag/CS Date: ________ Time: ________ EBL: _____ IOL for ____________
☐Allergies
☐Assess ☐Note
Blood: _____ Rhog: ___ GBS: + / - tx: Y/N Rub: Im / NI Hep B: + / - RPR: NR / R HIV: + / -
☐Care Plan
HX:____________________________________________________________
______________________________________________________________
☐Education
☐Love Note
Fundus: ______@ ____ Lochia: _______ Incision: ____________ CHG: _______
IV: _______ QL/Out Foley: Y/N DC @ _____ Voids: ______ ______ ______
Scheduled Meds:
PRN Meds:
Hg: _____ Hct: ______ Plts: _____ WBC: _____
Assessment:
Other: ________________________________
PPD: _____ DV: Y / N
SS: Y / N
D/C orders? Y / N _______
Flu: R / D
D/C Class
B/G Name: ____________ Gestation: _____ wks _____ days
Peds: _________ Apgars: ___ /____ Type: _____ Coombs: _____ Meds: ___
Birth wt: _______ Recent wt: _______ Loss: _____% Grw: _____Ballard: _____
Assessment: HUGS ________
Vitals q ____
Time
HR
RR
Temp
☐Report Note
☐Imm.
☐Allergies
☐Assessment
☐Assess Note
☐CP
☐Education
Feeds: breast / bottle pump / DHM
Time
L
R
mL
V ___
S ___
☐Lact Algo: P / R / D CCHD: P / F PKU: Y / N
☐Bath
CST: P / F
Chems:
☐Love Note
SGA / LGA / GDM / LPT
Labs due: _________________
☐D/C order
TCB: _____ @ _____ hrs = ______ IT: ______
TCB: _____ @ _____ hrs = ______
TSB: _____ @ _____ hrs = ______
Time
HR
RR
O2
Temp
U/O
DTR
Lung S
HA/vis