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					Evaluation, procedure(s):                       scheduled          unscheduled                              Date:                      To:                        By:       Walk             W/C        Stretcher
         NST         Observation            OCT             Other                                           Time in:                               From:       Home             Clinic
                                                                                                           Age       Grav Term Preterm AB           Liv    EDC dates    Gest. (wks)       EDC sono       Gest. (wks)
Indication(s)                                                      LMP
           Vital Signs                                          Fetal Heart Rate                                    Contractions                            Cervix                        Assessment Codes
TIME               BP       T       P       R       Mode       Baseline    Variab   Accels Decels            Freq      Duration   Intens     Dil     Eff     Station     Pres     Init.   Fetal Heart Rate
                                                                                                                                                                                          Monitor Mode
                                                                                                                                                                                          U/S – Ultrasound
                                                                                                                                                                                          T – Tocotransducer

                                                                                                                                                                                          AB – Absent
                                                                                                                                                                                          P – Present

                                                                                                                                                                                          VTX – Vertex
                                                                                                                                                                                          B – Breech *
                                                                                                                                                                                          T – Transverse
                                                                                                                                                                                          U – Unknown
                                                                                                                                         Periodic/Non Periodic                            O – Oblique
Membranes:                Int.          Bulging       Fern - / +           Nitrazine - / +                 Patient oriented to unit
                                                                                                           and call system.              ++ - (15 BPM – baseline x 15                     Intensity
                SROM:           Date:                           Time:                                      Clinical condition,                sec)                                        1 – Fair
                                     Patient Notes                                                         procedures, plan of           + - (15 BPM x 15 sec)                            2 – Moderate
                                                                                                           care explained.               V - Variable                                     3 – Strong
                                                                                                           Patient verbalizes            E - Early
                                                                                                           understanding.                L - Late                                         * See Nurse’s Notes
                                                                                                                                         M - Mixed
                                                                                                              Time                Medication           Response       Init.               ALLERGIES          None

                                                                                                           Time                    Orders                     See separate order sheet

         Time ↑      Device/Size     Solution       Rate Time      ↓   ccs Infuse Init.

                                                                                             Final Assessment

                                 Final Assessment Plan
                  Reactive Parameters: ≥              FHR accels in        min.
                         (accelerations ≥ 15 seconds duration ≥ 15 BPM amplitude)

                  Nonreactive * (not supine, no recent cigarette)
                  Unsatisfactory *
                  Decelerations present *              * Describe in notes
              Interpreted by:                                                                                                                                                                        RN/MD/CNM
          Negative                                              Spontaneous                  Discharge Instructions                                  N/A               See copy attached
Stress Test

          Positive *                                            Nipple stimulation
          Suspicious *                                          Oxytocin challenge
          Hyperstimulation *
          Variable Decels *
          Unsatisfactory *                                       * Describe in notes
      Interpreted by:                                                                                      Patient verbalizes understanding
Disposition:      Admitted *             See admit record                 Discharged                                                                                                Discharge/RN’s Signature
Time discharged or admit decision made:                                                      PATIENT IDENTIFICATION

To: Home /                                        Condition:
By:           Walk       W/C            Alone     With:
Initials                                    Signature/Title

Obstetric Assessment & Evaluation
N5821 Rev. (12/31/2003)
Obstetric Assessment & Evaluation                                                       Guidelines
Form #N5821
Procedure: Complete this form on all patients who are seen in an outpatient status in the obstetric
unit. This may include nonstress tests, labor checks, evaluations for fetal well being, etc.

           Enter patient name, outpatient number and physician name in addressograph box area.

           The RN, LPN or LDR technician may complete the top three lines. This information may be
            obtained from the prenatal record or patient.

           Note reason for visit. Enter indication why patient has presented, i.e., abdominal pain, etc.

           Gestation is noted by dates and ultrasound. Enter gestation using weeks plus days, i.e.,
            38w + 2d.

           Vital Signs: These may be entered by the RN, LPN or LDR technician. The first entry
            reflects admission vitals including FHR and contractions. Use assessment codes as noted in
            key. If cervical exam is performed, enter findings. Place your initials in final column.

           Ongoing entries entered per standard and at least hourly.

           Patient Notes: Note significant interventions or notation by any member of the healthcare

           IV: Use this section if hydration is ordered. Enter time fluids are hung. For Device/Size,
            enter gauge of catheter. Fill all other columns per heading. Leave no blanks. When IV
            discontinued, you may note this in the next available line.

           Medication: If meds are ordered, i.e., terbutaline, you may document medication here. Enter
            the response to the medication as well as nurse’s initials. If no meds are used, this area will
            be blank.

           Orders: Physician’s orders may be entered here, i.e., NST for decreased fetal movement,
            etc. If an additional order sheet is added to the chart, enter an “X” in the box.

           Final Assessment Plan: Note the response of the fetal monitor strip. Do not leave blank.
            Enter name of person interpreting strip. Use either the NST or Contraction Stress test as

           Instructions/Follow-up: Enter final physical assessment and plan of care for patient. This
            may include when to return to hospital, office visit, etc.

           Discharge Instructions: N/A is marked only if patient is admitted. Enter what instructions
            verbal or written are provided to the patient. This may include labor precautions sheet, etc.
            Mark an “X” that patient understands instructions.

           Initials/Signature/Title Area: Each person documenting on the assessment/evaluation must
            initial and sign full legal signature with title.

           Patient Identification Area: Stamp with the patient’s addressograph plate. Because this
            form is intended for use at several facilities, the addressograph should include facility
            identification information in addition to patient information.
N5821 Rev. (12/31/2003)

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