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)
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
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 Plan
Reactive Parameters: ≥ FHR accels in min.
(accelerations ≥ 15 seconds duration ≥ 15 BPM amplitude)
Nonreactive * (not supine, no recent cigarette)
Decelerations present * * Describe in notes
Interpreted by: RN/MD/CNM
Negative Spontaneous Discharge Instructions N/A See copy attached
Positive * Nipple stimulation
Suspicious * Oxytocin challenge
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:
Obstetric Assessment & Evaluation
N5821 Rev. (12/31/2003)
Obstetric Assessment & Evaluation Guidelines
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
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)