7/18/2019 Labor Delivery Triage

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L&D Triage Note

www.medfools.com  Thanks James, OSHU

S

name

age

G_P_ _ _ _ 

LMP

#wks @ dating US

EDC (LMP/US)

CC

HPI

Amniotic fluid

Bleeding / discharge

Contractions (start,freq, strength)

Dysuria

Eclapsia (HA,  !vision,midepigastric/RUQ pain)

Fetal movement

ROS

PMH

prenatal provider & clinic

abnormal PAP,colp, LEEP, cone

STD, HIV, GBS

other 

SURG

MED/ALL

SH/FH

A

O

VS

gen

heart

lungs

abdomen / uterus

extremities

SVE (D/E/S)MEM (S/AROM)

FHT (HR/V/A/D)

CTX (TOCO)

LABS (CBC,UA)

P

mom wellbeing

labor stage

fetus wellbeing (FHT)

pain (using)

other:* PET (stable, Mg, labs)* DM (meds, CBG)* fever (Abs, Tylenol)