Download 2. Health History PATIENT IDENTIFICATION

1.
INITIAL PREGNANCY PROFILE
IDENTIFICATION
PATIENT
Date:
History since LMP
Check and detail positive findings below.
Precede findings with symptom number.
15. Nutritional Assessment:
Adequate
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
Headaches
Nausea/vomiting
Abdominal pain
Urinary complaints
Vaginal discharge
Vaginal bleeding
Oedema (specify area
Febrile episode
Rubella exposure
Viral exposure
Drug exposure
Radiation exposure
Other
Last contraceptive:
Type:
Date last used:
Inadequate
Remarks……………………………………………………..
………………………………………………………………
………………………………………………………………
………………………………………………………………
………………………………………………………………
16.
Medication since LMP
(Rx, non-Rx, vitamins)
None
Describe……………………………………………………
………………………………………………………………
………………………………………………………………
………………………………………………………………
Initial Physical Examination
System
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
Height
Weight
Pre-gravid weight
BP
Normal
Check and detail all positive findings below
38. SS
Notch
Skin
EENT
Mouth
Neck
Chest
Breast
Heart
Lungs
Abdomen
Muskuloskeletal
Extremities
Neurological
Pelvic Examination
29
30
31
32
33
34
35
External genitalia
Vagina
Cervix
Uterus (describe)
Adnexa
Rectum
Other
Bony Pelvis
36. Diagnostic
Conj.
37. Shape
Sacrum
40
40. Pubic arch
41. Trans.
39. Ischial
Spines
42. Post sag.
Outlet
Exam by:
43. Coccyx
diam
44. Classification
Gynaecoid
Android
Anthropoid
45. Estimation:
Adequate
Borderline
Contracted
Platypelloid
Pulse
Optional
2. Health History
PATIENT
IDENTIFICATION
Summary
Date:
Patient’s
name…………………………..
…………………………………
Age____Race______Religion______Marital Status_______Years Married____Education_____ Occupation_________
Home
Home
Work
Adress_______________________________________________________tel.________________tel.______________
Nearest
Relative’s
Work
Relative____________________________ Employer___________________________________Tel.______________
Referring
Attending
Physician___________________________ Physician________________________
Medical History
Sensitivities
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
Congenital anomalies
Genetic diseases
Multiple births
Diabetes mellitus
Malignancies
Hypertension
Heart disease
Rheumatic fever
Pulmonary disease
GI problems
Renal disease
Other urinary tract problems
Genitourinary anomalies
Abnormal uterine bleeding
30.
None known
31.
Antibiotics
32.
Analgesics
33.
Sedatives
Anaesthesia
Other
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
Infertility
Venereal disease
Phlebitis, varicosities
Nervous/mental disorders
Convulsive disorders
Metabol./endocrine disorders
Anaemia/haemoglobinopathy
Blood dyscrasias
Drug addiction
Smoking/alcohol
Infections diseases
Operations/accidents
Blood transfusions
Other hospitalisations
No known disease
Menstrual
Onset
Cycle
34.
35.
Pre-existing Risk Guide
Indicates pregnancy/outcome at risk
36.
Age
37.
8th Grade Education
38.
Cardiac disease
39.
Tuberculosis, active
40.
Chronic pulmonary disease
41.
Thrombophlebitis
42.
Endocronopathy
43.
Epilepsy
44.
Infertility
45.
Abortions
46.
> 7 deliveries
47.
Previous pre-term or SGA infants
48.
Infants > 4,000 gms
49.
Isoimmunisation (ABO etc)
50.
Haemorrhage during previous preg.
51.
Previous pre-eclampsia
52.
Surgically scarred uterus
53.
____________________
Length
Amount
Indicates pregnancy/outcome at high risk
54.
Age > 40
55.
Diabetes mellitus
56.
Hypertension
57.
Cardiac disease (class III or IV)
58.
Chronic renal disease
59.
Congenital/chromosomal anomalies
60.
Haemoglobinopathies
61.
Immunisation
62.
Drug addiction/alcoholism
63.
Habitual abortions
64.
Incompetent cervix
65.
Prior fetal or neonatal death
66.
Prior neurologically damaged infant
67.
_____________________________
3.
PRENATAL FLOW RECORD
PATIENT IDENTIFICATION
Patient’s Name__________________________
Risk Guide for Pregnancy and Outcome
LabFindings
Preliminary Risk Assessment
No risk factors Noted
Hct/Hgb
(1) At risk
(2) High risk
Initial Prenatal
Mo day Test
/
/
/
/
/
/
/
/
/
Result
Hct/Hgb
Screen
Additional
Mo/day Test
Patient’s
blood type
And Rh
Father’s
and RH/
blood type
Antibody
Serology
Rubella titre
Urinalysis
micro
Pap test
G.C.
/
Hct/Hgb
/
/
/
/
/
Continuing Risk Guide (enter dates first noted and revisit RISK STATUS)
Mo/day
/
/
/
/
/
/
/
/
/
/
Potential risk factors
3. Preg. Without family support
4. Second pregnancy in 12 months
5. Smoking > 1 pack per day
6. Rh negative (non-sensitised)
7. Uterine/cervical malformation
8. Inadequate pelvis
9. Venereal disease
10 Anaemia(Hct < 30%:Hgb <10%)
11 Acute pyelonephritis
12 Failure to gain weight
Mo/day
/
/
/
/
/
/
/
/
/
/
/
13 Multiple pregnancy (term)
/
/
/
14 Abnormal presentation
15 Post-term pregnancy
/
/
High Risk factors
18. Diabetes mellitus
19. Hypertension
20. Thrombophlebitis
21. Herpes (type 2)
22. RH sensitisation
23. Uterine bleeding
24. Hydramnios
25. Severe pre-eclampsia
26. Fetal growth retardation
27. Premature rupt.
Membranes
28. Multiple pregnancy preterm
29. Low/falling oestriols
30. Significant social
problems
Flow Chart:
Weight this visit:

Attends prenatal classes
Blood Pressure:

Caesarean Section
Protein:

For sterilisation

Breast

Circumcision
 Bottle Feeding
Sugar:
Est. weeks/gestation:
Fundal Height:
Anaesthesia:
Fetal Heart Rate:
Baby’s Physician
Edema:
Risk Status (0, 1, 2)
Result
/
4. PRENATAL FLOW
PATIENT
IDENTIFICATION
RECORD
(Supplemental)
Patient’s Name…………………
………………………………………...
Date:
Weight this visit:
Blood Pressure:
Urine - Protein
Sugar
Est. weeks gestation:
Fundal height:
Fetal heart rate:
Oedema:
Risk status (0,1,2):
Quickening Date:
5. OBSTETRIC ADMITTING RECORD
Basic Admission Data –
Significant Prenatal Data
LMP:
EDC:
AGE:
Ambulatory:
Wheelchair:
Stretcher:
Next of Kin:
Tel. No.
 None
Prenatal Lab Tests
Patient’s
Blood type
Father’s
blood type
Rh
Titre
Rubella
titre
Reasons for Admission –
Onset of labour
Spontaneous abortion
Observation/Evaluation
Caesarean Section
Induction of Labour: elective  indicated 
Medical Complication:  Obstetric Complication
Antibody
Serology
Fetal assessment tests
 None
Date
Test
Result
 Other
Patient Care Data
Allergies/sensitivities
 None
Contractions on admission
 None
Frequency_________Duration__________Quality_________Latest risk assessment  No risk factors noted at present
Began on (date) ____________________ time___________ At risk
1._________________4._________________
Membranes on admission:
 Intact
 High risk2._________________5._________________
Ruptured (date)_________________
3._________________6._________________

Fluid was clear

Meconium
Prenatal education

Foul smelling
Vaginal bleeding
 None
 Attended Classes
 Normal Show
 Bleeding (describe)  Received prenatal care
Patient has:
 Records available when admitted

Recent URI

Dentures
Source of prenatal data:

Exposed to infection

Contact lenses Baby’s Physician:

Vomiting

Glasses
Plans for anaesthesia
None planned
Admission Physical Examination
Specify type:
Ht.
Wt.
BP
Temp. Pulse Resp.
Last oral intake (date/time)
Current medications:
System WNL Abn.
HEENT
Patient Plans:
Fetal evaluation
Estimated weeks gest___________
 Private
 Semi-private
 Rooming in
Breasts

Fundal height_______________ Presentation: Position:
 Smoker
 Non-smoker
 Husband in delivery Heart and Lungs 
 Breast
 Bottle feeding
 Circumcision for boy Abdomen
fetal wt.___________ vertex
Estimated
FHR______________________
Face/brow
Other
Extremities

Station____________________
Breech
(type)_______________
Reflexes

Effacement________________  Transverse lie
Procedures:

Prep

Enema (results)
Dilatation_________________  Compound
Physician’s name :
Notified by:
Date:
Urine
Alb.
Glu.
Blood sent: am/pm
HCT
Hgb
Nurse attending
__________________
6. LABOUR PROGRESS CHART
Admission date
Admission time:
Blood type and Rh
Membranes are :
Intact 
Baby’s Physician:
Page
Effacement
%
Examination by:
Blood Pressure:
FHR:
Oxytocin
Frequency:
Duration
Quality:
TPR
Medications and Key Events
Ruptured

Bulging

7. LABOUR DELIVERY AND SUMMARY
Labour Summary
G T P A L Type
Presentation
Position
Vertex
Face or brow
Breech
Transverse lie
Unknown
Complications
Compound
None
No prenatal care
Preterm labour (<37 weeks)
Term (>42 weeks)
anomalies
Febrile (>100.4) when admitted
PROM (>12 hrs preadmit)
Meconium
Foul smelling fluid
Hyrdamnios
Abruption
Placenta previa
Bleeding-site undetermined
Toxaemia (mild) (severe)
Seizure activity
{Precipitous labour (<3hrs)
Prolonged labour (>20 hrs)
Prolonged latent phase
Prolonged active phase
Prolonged 2nd stage (>2.5 hrs)
Secondary arrest of dilatation
Cephalopelvic disproportion
Cord prolapse
Decreased FHT variability
Extended fetal bradycardia
Extended fetal tachycardia
Multiple late decelerations
Multiple variable decelerations
Acidosis (pH<7.2)
Anaesthetic complications
_____________________________
Delivery Data
Delivery Data
Infant Data
Method of Delivery
Delivery Anaesthesia None
Cephalic
Local
Epidural
Spontaneous
Type
Pudendal
Spinal
Low forceps
Paracervical
General
Mid-forceps
No. Agent/drug
Dose
Rotation
To
Vacuum extraction
No. Agent/Drug
Dose
Breech
Delivery Room Meds. None
Spontaneous
Partial extraction (assisted)
Agent/Drug
Dose Route
Total extraction
Forceps to A.C. head
Time:
Sig:
Caesarean (details in operation notes)
Low cervical: transverse
Agent/Drug
Dose Route
Low cervical: vertical
Classical
Caesarean
Placenta
Spontaneous
Expressed
Manual
Adherent
Curettage
Configuration
Normal
Abn.
Weighed (No) (Yes)_____gms
Cord
Cord
Time:
Sig.
Agent/Drug
Time:
Dose
Route
Sig:
Medications
None
Scalp care
Volume expander
Sodium bicarbonate
Drug antagonists
Umbilical catheter
Other
Initial Newborn Exam
No observed abnormality
Gross congenital
Mec. Staining
Trauma
Petechiae
Other
Describe______________
Chronology
Date
_____________________
EDC:
_____________________
Admitted:
_____________________
Membranes Ruptured:
_____________________
Onset of labour:
Basic Data
Nuchal cord
COMPLETE CERVICAL DIL.
True knot
2 3 Umbilical vessels
DELIVERY OF INFANT:
Cord blood to (lab) (refrig) (discard)
ID Bracelet no.
Hospital No.
Male
Episiotomy
DELIVERY OF PLACENTA:
None
Infant Data
Median
Apgar Scores At 1 min: At 5 min:
Mediolateral
Heart rate
Birth order
Female
Weight
_____________________________
Length
Vitamin K
Induction
None
Other
Respiration
ARM
Augmentation
ARM
Oxytoc
None
Oxytoc
Laceration
None
1 2 3 4 Degree perineal
Vaginal
Cervical
Uterine rupture
Other____________________
Muscle tone
Surgical Procedures/None
Resuscitation
_________________ __________
Tubal ligation
Oxygen
_________________ __________
Other
Bag and mask
AgNo3 1% or__________
Monitor
External
Internal
FHT
Medications
UC None
Total dosage
Sig:
Reflex irritation
Output
Skin colour
Spontaneous respiration
Urine
Meconium
Gastric
Living at transfer to:
_____________________
_________________ __________
Intubation
Time of last narcotic __________
Ext. cardiac massage
Deceased
Antepartum
Intrapartum
Neonatal
Date
Other
Remarks_________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
Assisting:
Attending:
Nurse
Data
8. INITIAL NEWBORN PROFILE
1. Basic Data (entered by nursing personnel) G T P A L
Mother’s name:
LMP
risk estimate
EDC
Delivery Date:
Time:
Apgar at: 1min.
5 min.
Male Female Ambiguous
2. Physical Examination
Date of exam:
Time of exam
Temperature
Respiration rate
Femoral pulse:
Normal Absent
Code:
1.
2.
3.
4.
5.





 = No abnormalities
Reflexes
Skin colour/lesions
Head/Neck
Eyes
ENT
Newborn Risk Indicators - Please review these along with the prior risk
information available to you, in order to arrive at your Initial
in part 3.
Observations at birth
Baby’s age at exam
Pulse rate
Weak
Delayed
 = Abnormalities present
6. 
7. 
8. 
9. 
10. 
Thorax
11.  Genitals
Lungs
12.  Anus
Heart
13.  Trunk/Spine
Abdomen 14.  Extremities/joints
Umbilicus 15.  Tone/Appearance
Description of abnormal findings – please describe your findings objectively.
Reserve your impressions or diagnoses for part 3 below. Please begin your
Findings with the reference number preceding each category.
____________________________________________________________________
____________________________________________________________________
within 24 hrs postpartum
 No risk factors noted
 Abnormal presentation
 Multiple birth
 Low birth weight
 Resuscitation at birth
 1 min. Apgar < 5
 5 min. Apgar < 7
 Placental abnormalities
 Two cord vessels
 Difficult catheterisation
 >20ml. Of gastric aspirate
 Small mandible  cleft palate
 Grunting
 Deep retractions
 Imperforate anus
 Pallor
 Jaundice
 Plethora
 Conclusions
 Decreased tone
 Congenital malformations




















No risk factors noted
Abdominal distension
Vomiting
Failure to pass meconium
(if skin not stained)
Melena
Apneoic episodes
Tachypneoea(transient)
See-saw breathing
Cyanosis
Petechiae/Ecchymoses
Jaundice
Pallor
Plethora
Fever
Hypothermia
Arrhythmia’s
Murmur
Lethargy
Tremors
Convulsions
____________________________________________________________________
____________________________________________________________________
4.
____________________________________________________________________
Gest. age by dates
Gest. age by exam
3. Impressions and Diagnosis
This infant is
classified as:
Initial Risk Estimate
 No risk factors noted
 Medium risk
 Low risk
 High risk
5.
Maturity Evaluation
Weight
Length
Chest circ.
Head circ.
 pre-term <37 weeks
 term 37 – 42 weeks
 Post-term >42 weeks
 SGA
 AGA
 LGA
Plans: diagnostic and therapeutic
____________________________________________________________________
____________________________________________________________________
________________________________________________
____________________________________________________________________
________________________________________________
____________________________________________________________________
________________________________________________
____________________________________________________________________
________________________________________________
____________________________________________________________________
________________________________________________
9. NEWBORN DISCHARGE SUMMARY
Physical Examination
Name:
last
Basic Data
Date of
Exam
Time of
Exam
Baby’s age
at Exam
Discharge weight:
Temperature:
Respiration
Rate:
Pulse
rate:
Tests
(Code:
Infant’s
first
 No abnormalities  Abnormalities present)
Mother’s record No.
Results
Date
Infant’s record No.
Blood Type:
Infant’s ID No.
1.  Reflexes
6.  Thorax
11.  Genitals
Coombs Serology
Sex:
2.  Skin colour, lesions
7.  Lungs
12.  Anus
PKU blood/urine
Race:
3.  Head/Neck
8.  Heart
13.  Trunk/Spine
Thyroid
DoB
4.  Eyes
9.  Abdomen
14.  Extremities/Joints
Place of Birth:
Hospital
5.  ENT
10.  Umbilicus
15.  Tone/Appearance
Description of Abnormal findings – Please describe your findings objectively.
Reserve your impressions or diagnosis for the Discharge section below. Please
Begin your findings with the reference number preceding the circled category.
If baby died note:
Age at death:
__________________________________________________________________
 With mother
__________________________________________________________________
 To another service
__________________________________________________________________
 To another hospital
__________________________________________________________________
 Against advice
__________________________________________________________________
Follow-up appointment:
__________________________________________________________________
 With private physician
Discharge Status – Use this section to summarise the baby’s present condition.
 At clinic
Describe briefly existing and resolved neonatal problems. If the baby is deceased
Note:
Explain the reasons for death.
Date:
Problem(1)_________________________________________________________
T4/TSH
Home
En route Other
Autopsy: Y/N
Newborn discharged on:
Signature:
Developed:
At birth
In nursery
Course of treatment and impressions – Please refer to the
Problem 1, 2, 3, or 4 in your summary. Note also your final
impression of the baby at discharge.
Status:
Resolved
Stable
________________________________________________
Diminished
Accelerated
________________________________________________
Problem (2)_________________________________________________________
________________________________________________
Developed:
At birth
In nursery
________________________________________________
Status:
Resolved
Stable
________________________________________________
Diminished
Accelerated
________________________________________________
Problem (3)_________________________________________________________
________________________________________________
Developed :
At birth
In nursery
________________________________________________
Status:
Resolved
Stable
________________________________________________
Diminished
Accelerated
________________________________________________
Problem (4)________________________________________________________
________________________________________________
Developed:
Status:
________________________________________________
Date:
At birth
Resolved
Diminished
In nursery
Stable
Accelerated
Physician’s signature:___________________________
________________________________________________