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SBAR Labor Delivery Report Hand Off Sheet and Assessment Tool 110411 Update PDF
SBAR Labor Delivery Report Hand Off Sheet and Assessment Tool 110411 Update PDF
Prenatal record reviewed _____ Medical history: (Chronic illnesses/surgeries) __________________________ Total Wt. gain _________ BMI________
Previous Pregnancy History: Date ______ (Vaginal or C/S) Labor duration ______ Sex ______ Infant Wt. ________ Complications ________________
Maternal VS: T_____ P_____ BP_____ R_____ Current Pain_____ Tolerable Pain Level_____ Last/Current Pain Medication (time)/Score_____/_____/
A
_____ Voiding______ Activity__________ Dil_____ Eff_____ Sta_____ ROM:Time/Color_________ Monitor: Internal/External (Circle) Contrx:
Freq______ Duration______ Intensity______ Fetal Presentation________ Position__________ FHR______ Variability_______ Periodic Changes:
Decels______ (Early, Late, Variable) Accels______ IV fluids_________ O2_______ Prostaglandins (Cervical ripening)_________________________
Student Schedule
Break_________ Lunch________ Clinical Conference ________________ Report off to Instructor _______ Report off to Staff RN __________
Notes
Adapted 01/19/17 from Research College of Nursing Mother-Baby Care Report (Hand-off) Form obtained from QSEN (SMachado, RNc-OB, MS)
History/Assessments Evergreen Valley College
Delivery Information:
Infant: Date _____________Time ____________ (Vaginal or C/S) _________Vacuum or forceps ________________________
Placenta: Time __________ Spontaneous or manual extraction ___________ Placental abnormalities _________________ ___
Length of Stage I _________ Stage II ___________ Stage IIII ____________ Estimated Blood Loss (EBL) ______________ __
Prioritized Problems/Diagnoses for Labor and Delivery Strategies/Interventions for Labor and Delivery
1. _____________________________________________ 1. ______________________________________________
_____________________________________________ ______________________________________________
2. _____________________________________________ 2. ______________________________________________
_____________________________________________ ______________________________________________
3. _____________________________________________ 3. ______________________________________________
_____________________________________________ ______________________________________________