Isbar Preeclampsia ATI

SBAR for Direct Patient Care Documentation Antepartum/Intrapartum I Introduce yourself Your Name: Your Title: Reason for being there: D#: Situation S Patient Initials: EDC: LMP: Singleton Twin Other Age: G____T____P____A____L____ Other: Gest. Age: /7 weeks Reason for Admit: Fetal Movement: Present Not Present Membrane Status: Intact Ruptured Date: Time: Fluid: Background B Previous Pregnancies: Year Type of Delivery Labor Length Complications Current Pregnancy – Prenatal Care: Yes No Labs: Complications: Past Medical History: Home Medications: GBS Status: Positive Negative Breast Feeding: Yes No Family Support: A Assessment Vital Signs Temp B/P HR RR SP02 Pain FHTS Labor status: Onset: Stage/Phase: Vaginal exam: / / Blood/Fluid: Planned method of delivery: Vaginal C/Section Contraction pattern: frequency: Duration: Strength: Labor progress: Maternal physical assessment: IV: Current meds: Labs: Activity: R Recommendation Discharge planning needs: Sabrina Jacques