|
1. Prenatal Visit Date
|
EDD
|
|
Weight
|
|
|
Urine Protein/Glucose/Blood/Leukocytes:
• • •
|
Gest Age weeks
|
|
Urine Comments
|
Urine for culture
|
|
Fundal Ht:
|
FHR NORMAL
|
|
Presentation Cephalic?
|
Fetal Movement
|
|
Preterm Labor Symptoms
|
VE
|
|
Edema
|
|
|
Subjective
• • •
|
SUBJECTIVE COMMENTS
|
|
Objective
• • •
|
Objective Comments
|
|
Assessment
• • •
|
Assesment Comments
|
|
Plan/Orders:
• • •
|
Plan Comments
|
|
Discussed
• • •
|
Comment(s):
|
|
RTO
• • •
|
Additional labs ordered
|
|
2. Prenatal Visit Date
|
Weight
|
|
Urine Protein/Glucose/Blood/Leukocytes:
• • •
|
Gest Age weeks
|
|
Urine Comments
|
Urine for culture
|
|
Fundal Ht:
|
FHR NORMAL
|
|
Presentation Cephalic?
|
Fetal Movement
|
|
Preterm Labor Symptoms
|
VE
|
|
Edema
|
|
|
Subjective
• • •
|
SUBJECTIVE COMMENTS
|
|
Objective
• • •
|
Objective Comments
|
|
Assessment
• • •
|
Assesment Comments
|
|
Plan/Orders:
• • •
|
Plan Comments
|
|
Discussed
• • •
|
Comment(s):
|
|
RTO
• • •
|
Additional labs ordered
|
|
3. Prenatal Visit Date
|
Gest Age weeks
|
|
Weight
|
Urine Protein/Glucose/Blood/Leukocytes:
• • •
|
|
Urine for culture
|
Urine Comments
|
|
Fundal Ht:
|
FHR NORMAL
|
|
Presentation Cephalic?
|
Fetal Movement
|
|
Preterm Labor Symptoms
|
VE
|
|
Edema
|
|
|
Subjective
• • •
|
SUBJECTIVE COMMENTS
|
|
Objective
• • •
|
Objective Comments
|
|
Assessment
• • •
|
Assesment Comments
|
|
Plan/Orders:
• • •
|
Plan Comments
|
|
Discussed
• • •
|
Comment(s):
|
|
RTO
• • •
|
Additional labs ordered
|
|
4. Prenatal Visit Date
|
Gest Age weeks
|
|
Weight
|
|
|
Urine Protein/Glucose/Blood/Leukocytes:
• • •
|
Urine for culture
|
|
Urine Comments
|
|
|
Fundal Ht:
|
Fetal Movement
|
|
FHR NORMAL
|
VE
|
|
Presentation Cephalic?
|
|
|
Preterm Labor Symptoms
|
|
|
Edema
|
|
|
Subjective
• • •
|
SUBJECTIVE COMMENTS
|
|
Objective
• • •
|
Objective Comments
|
|
Assessment
• • •
|
Assesment Comments
|
|
Plan/Orders:
• • •
|
Plan Comments
|
|
Discussed
• • •
|
Comment(s):
|
|
RTO
• • •
|
Additional labs ordered
|
|
5. Prenatal Visit Date
|
Gest Age weeks
|
|
Weight
|
Urine Protein/Glucose/Blood/Leukocytes:
• • •
|
|
Urine for culture
|
Urine Comments
|
|
Fundal Ht:
|
FHR NORMAL
|
|
Presentation Cephalic?
|
Fetal Movement
|
|
Preterm Labor Symptoms
|
VE
|
|
Edema
|
|
|
Subjective
• • •
|
SUBJECTIVE COMMENTS
|
|
Objective
• • •
|
Objective Comments
|
|
Assessment
• • •
|
Assesment Comments
|
|
Plan/Orders:
• • •
|
Plan Comments
|
|
Discussed
• • •
|
Comment(s):
|
|
RTO
• • •
|
Additional labs ordered
|
|
6. Prenatal Visit Date
|
Gest Age weeks
|
|
Weight
|
Urine Protein/Glucose/Blood/Leukocytes:
• • •
|
|
Urine for culture
|
Urine Comments
|
|
Fundal Ht:
|
Fetal Movement
|
|
Presentation Cephalic?
|
FHR NORMAL
|
|
Preterm Labor Symptoms
|
VE
|
|
Edema
|
|
|
Subjective
• • •
|
SUBJECTIVE COMMENTS
|
|
Objective
• • •
|
Objective Comments
|
|
Assessment
• • •
|
Assesment Comments
|
|
Plan/Orders:
• • •
|
Plan Comments
|
|
Discussed
• • •
|
Comment(s):
|
|
RTO
• • •
|
Additional labs ordered
|
|
7. Prenatal Visit Date
|
Gest Age weeks
|
|
Weight
|
Urine Protein/Glucose/Blood/Leukocytes:
• • •
|
|
Urine for culture
|
Urine Comments
|
|
Fundal Ht:
|
FHR NORMAL
|
|
Presentation Cephalic?
|
Fetal Movement
|
|
Preterm Labor Symptoms
|
VE
|
|
Edema
|
|
|
Subjective
• • •
|
SUBJECTIVE COMMENTS
|
|
Objective
• • •
|
Objective Comments
|
|
Assessment
• • •
|
Assesment Comments
|
|
Plan/Orders:
• • •
|
Plan Comments
|
|
Discussed
• • •
|
Comment(s):
|
|
RTO
• • •
|
Additional labs ordered
|
|
8. Prenatal Visit Date
|
Gest Age weeks
|
|
Weight
|
Urine Protein/Glucose/Blood/Leukocytes:
• • •
|
|
Urine for culture
|
Urine Comments
|
|
Fundal Ht:
|
FHR NORMAL
|
|
Presentation Cephalic?
|
Fetal Movement
|
|
Preterm Labor Symptoms
|
VE
|
|
Edema
|
|
|
Subjective
• • •
|
SUBJECTIVE COMMENTS
|
|
Objective
• • •
|
Objective Comments
|
|
Assessment
• • •
|
Assesment Comments
|
|
Plan/Orders:
• • •
|
Plan Comments
|
|
Discussed
• • •
|
Comment(s):
|
|
RTO
• • •
|
Additional labs ordered
|
|
9. Prenatal Visit Date
|
Gest Age weeks
|
|
Weight
|
Urine Protein/Glucose/Blood/Leukocytes:
• • •
|
|
Urine for culture
|
Urine Comments
|
|
Fundal Ht:
|
FHR NORMAL
|
|
Presentation Cephalic?
|
Fetal Movement
|
|
Preterm Labor Symptoms
|
VE
|
|
Edema
|
|
|
Subjective
• • •
|
SUBJECTIVE COMMENTS
|
|
Objective
• • •
|
Objective Comments
|
|
Assessment
• • •
|
Assesment Comments
|
|
Plan/Orders:
• • •
|
Plan Comments
|
|
Discussed
• • •
|
Comment(s):
|
|
RTO
• • •
|
Additional labs ordered
|
|
10. Prenatal Visit Date
|
Gest Age weeks
|
|
Weight
|
Urine Protein/Glucose/Blood/Leukocytes:
• • •
|
|
Urine for culture
|
Urine Comments
|
|
Fundal Ht:
|
FHR NORMAL
|
|
Presentation Cephalic?
|
Fetal Movement
|
|
Preterm Labor Symptoms
|
VE
|
|
Edema
|
|
|
Subjective
• • •
|
SUBJECTIVE COMMENTS
|
|
Objective
• • •
|
Objective Comments
|
|
Assessment
• • •
|
Assesment Comments
|
|
Plan/Orders:
• • •
|
Comment(s):
|
|
Discussed
• • •
|
Plan Comments
|
|
RTO
• • •
|
Additional labs ordered
|
|
11. Prenatal Visit Date
|
Gest Age weeks
|
|
Weight
|
Urine Protein/Glucose/Blood/Leukocytes:
• • •
|
|
Urine for culture
|
Urine Comments
|
|
Fundal Ht:
|
FHR NORMAL
|
|
Presentation Cephalic?
|
Fetal Movement
|
|
Preterm Labor Symptoms
|
VE
|
|
Edema
|
|
|
Subjective
• • •
|
SUBJECTIVE COMMENTS
|
|
Objective Comments
|
Objective Comments
|
|
Assessment
• • •
|
Assesment Comments
|
|
Plan/Orders:
• • •
|
Plan Comments
|
|
Discussed
• • •
|
Comment(s):
|
|
RTO
• • •
|
Additional labs ordered
|
|
12. Prenatal Visit Date
|
Gest Age weeks
|
|
Weight
|
Urine Protein/Glucose/Blood/Leukocytes:
• • •
|
|
Urine for culture
|
Urine Comments
|
|
Fundal Ht:
|
FHR NORMAL
|
|
Presentation Cephalic?
|
Fetal Movement
|
|
Preterm Labor Symptoms
|
VE
|
|
Edema
|
|
|
Subjective
• • •
|
SUBJECTIVE COMMENTS
|
|
Objective
• • •
|
Objective Comments
|
|
Assessment
• • •
|
Assesment Comments
|
|
Plan/Orders:
• • •
|
Plan Comments
|
|
Discussed
• • •
|
Comment(s):
|
|
RTO
• • •
|
Additional labs ordered
|
|
13. Prenatal Visit Date
|
Gest Age weeks
|
|
Weight
|
Urine Comments
|
|
Urine Protein/Glucose/Blood/Leukocytes:
• • •
|
Fundal Ht:
|
|
Urine for culture
|
Presentation Cephalic?
|
|
FHR NORMAL
|
Preterm Labor Symptoms
|
|
Fetal Movement
|
Edema
|
|
VE
|
|
|
Subjective
• • •
|
SUBJECTIVE COMMENTS
|
|
Objective
• • •
|
Objective Comments
|
|
Assessment
• • •
|
Assesment Comments
|
|
Plan/Orders:
• • •
|
Plan Comments
|
|
Discussed
• • •
|
Comment(s):
|
|
RTO
• • •
|
Additional labs ordered
|
|
14. Prenatal Visit Date
|
Gest Age weeks
|
|
Weight
|
Urine Comments
|
|
Urine Protein/Glucose/Blood/Leukocytes:
• • •
|
Fundal Ht:
|
|
Urine for culture
|
Presentation Cephalic?
|
|
FHR NORMAL
|
VE
|
|
Fetal Movement
|
|
|
Preterm Labor Symptoms
|
|
|
Edema
|
|
|
Subjective
• • •
|
SUBJECTIVE COMMENTS
|
|
Objective
• • •
|
Objective Comments
|
|
Assessment
• • •
|
Assesment Comments
|
|
Plan/Orders:
• • •
|
Plan Comments
|
|
Discussed
• • •
|
Comment(s):
|
|
RTO
• • •
|
Additional labs ordered
|
|
15. Prenatal Visit Date
|
Gest Age weeks
|
|
Weight
|
Urine Comments
|
|
Urine Protein/Glucose/Blood/Leukocytes:
• • •
|
Fundal Ht:
|
|
Urine for culture
|
Presentation Cephalic?
|
|
FHR NORMAL
|
Preterm Labor Symptoms
|
|
Fetal Movement
|
Edema
|
|
VE
|
|
|
Subjective
• • •
|
SUBJECTIVE COMMENTS
|
|
Objective
• • •
|
Objective Comments
|
|
Assessment
• • •
|
Assesment Comments
|
|
Plan/Orders:
• • •
|
Plan Comments
|
|
Discussed
• • •
|
Comment(s):
|
|
RTO
• • •
|
Additional labs ordered
|
|
RECORDS FAXED TO L&D
|
|
