ISBAR Post Partum Newborn and BSN Level 3 Direct patient Care Documentation

I Introduce yourself

Your Name: Your Title: Reason for being there:

D#:

S Situation

Patient Initials:

Delivery Date:

Sex: Male / Female

Length of labor:

Amniotic fluid rupture: ❑ SROM ❑ AROM

Type of delivery: ❑ Vaccum ❑ Forceps

Episiotomy/Lacerations:

APGAR: 1min 5 min 10 min

Complications:

Age: G____T____P____A____L____

Time: Gest. Age: /7 weeks

Singleton Twin Other

1st stage________ 2nd stage________ 3rd stage_________

Time: Fluid:

Cesarean – indication Type of incision

EBL:

Resuscitation measures:

B Background

Previous Pregnancies:

Current Pregnancy Prenatal Care: ❑ Yes ❑ No GBS Status: pos neg Breast Feeding: ❑ Yes ❑ No Labs: Complications: Past Medical History: Family Support: Home Medications:

A Assessment

MOTHER NEWBORN

Temp: BP: HR: RR: Pain: Temp: BP: HR: RR: Pain:

General: Birth weight: LB: OZ: / grams

Activity: Length: Head: Chest:

Cardiovascular: Gest. Age by Ballard: SGA/AGA/LGA

Resp: General appearance: (Activity/tone/cry)

Breast:

Uterus: Skin:

Bowel: Head and neck:

Bladder: Chest/Cardio/Resp:

Lochia:

Perineum: Abdomen:

Hemorrhoids: Musculoskeletal:

COLLEGE of NURSING

National Management Office | 3005 Highland Parkway, Downers Grove, IL 60515 | 888.556.8226 | chamberlain.edu

Please visit chamberlain.edu/locations for location specific address, phone and fax information.

12-200083 ©2020 Chamberlain University LLC. All rights reserved. 0420culcpe

YEAR TYPE OF DELIVERY LABOR LENGTH COMPLICATIONS

I-SBAR FOR DIRECT PATIENT CARE DOCUMENTATION POST-PARTUM/NEWBORN

A Assessment

MOTHER NEWBORN

Extremities: Genitourinary:

RhoGam needed: ❑ YES ❑ NO Reflexes present: Chest:

IV: MEDS: Gest. Age by Ballard: SGA/AGA/LGA

Labs: Output: Void Stool

Psycho social adaptation/ Rubin’s Phase:

Labs:

R Recommendation

Discharge Planning Needs:

Plan of Care: Nursing Analysis/ Priority Diagnosis:

Patient Goal:

Outcome Criteria:

Met/ Not met/ Partially met

PRIORITY INTERVENTIONS REASONING EVALUATION OF INTERVENTION

1.

2.

3.

4.

5.

COLLEGE of NURSING

National Management Office | 3005 Highland Parkway, Downers Grove, IL 60515 | 888.556.8226 | chamberlain.edu

Please visit chamberlain.edu/locations for location specific address, phone and fax information.