Maternal/Newborn

Record System

Obstetric Triage Record

To order call: 1.800.245.4080

Patient Data

Re-order No. 5709N

c Ambulatory

c Stretcher

c Wheelchair

c Transfer From ___________________________________________

Pt

c Other ______________________________

E
D
D

L
M
P

Gestation ____________ wks

c None
c Latex
c Food
c Other _______________________________________________

Allergy/Sensitivity

Date ____/____/____ Time_____________

Age

DOB

Prenatal Records Available c NO c YES

c No Prenatal Care
MD/CNM

MD/PNP (Newborn)

p
r
o

Prenatal Care Provider_______________________________________________________

Wt. Pregrav./Grav.

Height

Physical Assessment

i
r
B

No

Yes

c None __________________ __________ c c ________________

__________________ __________ c c ________________
Membranes
c Intact c Bulging c Ruptured (Date____/____/____Time_________)
c Nitrazine Test ( c pos c neg) c Sterile Speculum Exam
c Fern Test
( c pos c neg) (findings________________________)
c Amnisure
( c pos c neg)
Fluid c None Seen c Clear c Bloody c Foul Odor c Meconium Stained
Vaginal Bleeding
c None c Normal Show c Bleeding (describe____________________)

A
S

E
L

FHR/Contractions

TIME

TIME

FHR

TEMP

Cervical Exam

TIME
DILAT

VARIABILITY
ACCELS

PULSE

EFF

DECELS

RESP

STAT

FREQ

DURA

BP

INTEN

43

c Palpation c External Monitor

O2 SAT

3
2
7-

PRES

Exam by ________________

Notes /Interventions:____________________________________________

____________________________________________________________________
____________________________________________________________________
_____________________________________ Initials
Signature
_____________________________________
_____________________________________
_____________________________________

0
0
(8

Psychosocial Assessment

Observation Evaluation
c Fetal Status
c Ultrasound
c Amniocentesis
c NST c CST c FAST
c Fetal Movement
___________________
___________________
c Medical Complications
___________________
___________________
c Obstetric Complications
___________________
___________________

EFM/STRIP # ________________

P
M

Illness (less than or equal to 14 days prior) c None c _______________

Recent Exposure to Illness and Disease (Flu, Varicella, T.B., Hepatitis, HIV)
c None c Type/Date__________________________ ____ /____ /____
Nutritional Problems c No c Yes ________________________________
Last Oral Intake
Fluids____ /____ /____ Time_________
Solids____ /____ /____ Time_________
Type / Dose
Last Taken With Patient
Disposition
Medications

.
w
w

m
o
.c

Vital Signs

C
s
gg

General Health c Good c Significant history______________________

_____________________________________________________________

c Possible Onset of Labor Time_____________

c PROM c SROM
c Vaginal Bleeding c Preterm Labor
c Trauma ________________________________
c Pain: 0-10____ Site:______________________
Type: c Aching c Nagging c Dull c Heavy
c Crushing c Sharp c Stabbing
c Throbbing c Radiating c Burning
c Tingling c Cramping c Other:_________
c Preeclampsia c Fetal Activity
c Hyperemesis
c ______________________________________

Notified By__________________________________ Date ____/____/____ Time________

Reason Patient is Presenting:

4
2
)

Partner Involved c No c Yes

Communication Barriers c None c ___________________________________________

Others Involved c No c Yes, Identify _________________________________

Free From Apparent Physical /Emotional Abuse c Yes c No ________________________

Substance Use No Yes

Tobacco
c c
Alcohol
c c
Drugs
___________ c c
___________ c c

_________________________________________________________________________
Self Care Needs c None c _________________________________________________
Emotional Status c Happy c Ambivalent c Concerned c Depressed
c Angry c Other___________________________________________

Amt /Day
Last Used
Time
_______________ ____ /____ /____ ___________
_______________ ____ /____ /____ ___________
_______________ ____ /____ /____ ___________
_______________ ____ /____ /____ ___________

Diagnosis & Disposition

Diagnosis

Disposition

Date____/____/____ Time_________________

c Antepartum Bleeding
c False Labor - Undelivered

c Transfer to ______________________________________

c Hyperemesis Gravidarum
c Placenta Previa

c Admit to Intrapartum unit

c Admit to Antepartum unit
c Discharge to home accompanied by __________________
c Unrestricted (or)___________________
Activity

c Preeclampsia
c Premature Labor - Resolved
c PROM x _______ Hours

consent form signed (cobra) c NO c YES c N/A

Diet

c Routine (or) ______________________

c Incompetent Cervix
c Active Labor

Medications

c None (or) ________________________

c UTI
c ________________________

Instructions

________________________________
c Routine (or) ______________________

Follow up

Where _____________________________

c ________________________

When ______________________________

Form 5709N Rev. 11/13 BRIGGS, Des Moines, IA (800) 245.4080

Unauthorized copying or use violates copyright law. www.BriggsCorp.com PRINTED IN U.S.A.

Orders ______________________________________________

____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
MD Signature

Date / Time

____________________________________________________
RN Signature

Date / Time

OBSTETRIC TRIAGE RECORD