I-SBAR for Direct Patient Care Documentation
Teaching Prenatal and Newborn Care
Your Name: Briana Maduray Your Title: Student Nurse_ Time:
I 0700
INTRODUCE
YOURSELF
Reason for Being There: Patient care
Date: 05/09/2020
Patient initials: CC Age: 28 G 1 T 0 P_0_A_0_L_0__ Allergies:
S NKA
SITUATION
Diet: Regular Height: not available Weight: not available
EDD: not available LMP: not available Trimester: third Obstetrician:
Trimble, George
□ Singleton □ Twin □ Other
Pediatrician:
Reason for visit: birth Patel, Aanya
Fetal movement: □ present □ not present
B Previous pregnancies NONE
BACKGROUND
Year Type of delivery Labor Length Complications
Current pregnancy
Prenatal care: □ yes □ no Breast feeding: □ yes □ no
Blood type/Rh: ______ Rubella:_____ Hep B: _______ HIV:_______ RPR: ______ GBS status: ______
Complications: gestational diabetes
Past Medical History: _____________ Social History: employed
Family Support: married, living with spouse
A Newborn: Initials: CC
ASSESSMENT
□Boy □Girl Delivery method: vaginal Birthdate: 09/18/XX Time: 0415
Apgar score – not available Resuscitation measures: full code
Birth weight 8 lb. 0 oz. g. Length: 52cm in/cm Head:___ in/cm Chest:____
in/cm Gestational Age Category: SGA: AGA: LGA: _
Safety checks: ID bands_______ Security Sensor:____ _ Bulb syringe:
Newborn Vital Signs:
TEMP B/P HR RR SP02 PAIN FHTs
36.8 ax Not available 144 36 Not avail. Not avail
36.9 ax Not avail 152 42 Not avail Not avail
36.8 ax Not avail 138 40 Not avail Not avail
This study source was downloaded by 100000832361371 from CourseHero.com on 04-03-2022 08:12:48 GMT -05:00
NR327 ISBAR Teaching Prenatal and Newborn Care Documentation New: May20
https://www.coursehero.com/file/61952772/NR-327-Newborn-Teaching-ISBARdocx/
Teaching Prenatal and Newborn Care
Your Name: Briana Maduray Your Title: Student Nurse_ Time:
I 0700
INTRODUCE
YOURSELF
Reason for Being There: Patient care
Date: 05/09/2020
Patient initials: CC Age: 28 G 1 T 0 P_0_A_0_L_0__ Allergies:
S NKA
SITUATION
Diet: Regular Height: not available Weight: not available
EDD: not available LMP: not available Trimester: third Obstetrician:
Trimble, George
□ Singleton □ Twin □ Other
Pediatrician:
Reason for visit: birth Patel, Aanya
Fetal movement: □ present □ not present
B Previous pregnancies NONE
BACKGROUND
Year Type of delivery Labor Length Complications
Current pregnancy
Prenatal care: □ yes □ no Breast feeding: □ yes □ no
Blood type/Rh: ______ Rubella:_____ Hep B: _______ HIV:_______ RPR: ______ GBS status: ______
Complications: gestational diabetes
Past Medical History: _____________ Social History: employed
Family Support: married, living with spouse
A Newborn: Initials: CC
ASSESSMENT
□Boy □Girl Delivery method: vaginal Birthdate: 09/18/XX Time: 0415
Apgar score – not available Resuscitation measures: full code
Birth weight 8 lb. 0 oz. g. Length: 52cm in/cm Head:___ in/cm Chest:____
in/cm Gestational Age Category: SGA: AGA: LGA: _
Safety checks: ID bands_______ Security Sensor:____ _ Bulb syringe:
Newborn Vital Signs:
TEMP B/P HR RR SP02 PAIN FHTs
36.8 ax Not available 144 36 Not avail. Not avail
36.9 ax Not avail 152 42 Not avail Not avail
36.8 ax Not avail 138 40 Not avail Not avail
This study source was downloaded by 100000832361371 from CourseHero.com on 04-03-2022 08:12:48 GMT -05:00
NR327 ISBAR Teaching Prenatal and Newborn Care Documentation New: May20
https://www.coursehero.com/file/61952772/NR-327-Newborn-Teaching-ISBARdocx/
