L&D documentation

[rubyagnes, BSN]

Does anyone have any L&D specific assessment sheets they could share? Curious how they might differ from basic acute care... (New RN here, if that wasn't obvious...) :)

[SoldierNurse22, BSN, RN]

I don't have an assessment "sheet", nor do I know of anyone at my facility who does. When you start in OB, you'll follow a preceptor and typically, between your preceptor and a textbook, you'll learn how to perform assessments specific to the OB population.

Are you looking for a checklist of what you need to be assessing/looking for when assessing OB patients? I would think most textbooks could provide you with something of that nature.

[rubyagnes, BSN]

@soldiernurse22 Thanks! Yeah, I just graduated and remember having basic head to toe assessment forms that we used during many med-surg clinicals, but didn't know if something like that existed for L&D... Just trying to plan ahead if I do end up taking the L&D new grad job. :) Thanks again!

[ashleyisawesome, BSN, RN]

At my hospital we don't use a full sheet SBAR report sheet like they do in med/surg. We do carry little cards (about the size of a 3x5). They have pt name, age, doctor, EGA, gravida/para, relevant medical/pregnancy history, gbs status, HIV status, Rubella immune/nonimmune, breastfeed/formula preference, Rupture time, and any meds/epidural given and time. On the back we usually write her cervical checks with the time and what doctor did them.

I do not do a full head to toe assessment. I do listen to heart/lungs, check homans, check for edema, assess pain, etc. But I would only note something on that card if it were abnormal(ie, a murmur, severe edema).

[rubyagnes, BSN]

Thanks @ashleyisawesome That sounds like a helpful tool :)

[lavenderskies, BSN]

At my hospital we don't use a full sheet SBAR report sheet like they do in med/surg. We do carry little cards (about the size of a 3x5). They have pt name, age, doctor, EGA, gravida/para, relevant medical/pregnancy history, gbs status, HIV status, Rubella immune/nonimmune, breastfeed/formula preference, Rupture time, and any meds/epidural given and time. On the back we usually write her cervical checks with the time and what doctor did them.

I do not do a full head to toe assessment. I do listen to heart/lungs, check homans, check for edema, assess pain, etc. But I would only note something on that card if it were abnormal(ie, a murmur, severe edema).

Ditto all of ashleyisawesomes comment and I would add assess for headache/vision changes and epigastric pain.