Sample

Charting LABOR ROOM

Date & Focus Data, Action, Response

time
Labor pain D> Into labor room a____________ y/o, G__P__ from OB ward / ER
accompanied by IWOD/ RNSE/ SNOD on duty; With ongoing IVF of _______1L+
_______ “u” oxytocin at ______ ml level infusing well at
metacarpal/cephalic/basilic vein.
> grimaces, moans occasionally, irritable at times, guarding lumbosacral area
noted; with vital signs of BP_____mmHg, PR____bpm, RR____cpm,
Temp._____°C
Patient Care A> Assessed level of pain. Assessed progress of labor. Monitored vital signs
and recorded. Assisted on ambulation; Massaged lumbosacral area.
Positioning and A> Assisted to DR table and positioned to litothomy for IE done
Comfort by________________ revealing ____cm cervical dilatation; Perineal shaving
done; Ushered to LR for further monitoring
Fluid and A> IVF of _______1L+_____ “u” oxytocin inserted by _________________at the
administration of L / R metacarpal/ cephalic/ basalis vein and regulated to ____________gtts/min.
medication
A> First dose HNBB 1 amp. given IV push by NOD / RNSE
A> Blood specimen extracted by medtech on duty for CBC, ABO typing and HB
Health Teaching A> Instructed on proper deep breathing techniques; Squatting to facilitate
descent; Maintained in NPO as ordered and encouraged to verbalize feelings
and concerns
R> Increased intensity of pain with pain scale of __________ and uterine
contractions occuring every 2-3 minutes; With duration of 60-90 seconds
Unit Transfer A> Brought to DR ambulatory with the same IVF accompanied
by________________.
TO BE INCLUDED IF IT WAS DONE
A> Bag of water ruptured artificial/spontaneously by_____________.
A> Seen and examined by Dr._______________ ordered for “E” Cesarean
section due to arrest of cervical dilatation/ arrest of descent; Scheduled for “E”
CS; Informed OR NOD, Pediatrician and Anesthesiologist.
Consent Secured consent for the procedure/operation signed by the patient/parent /
husband / relatives
 DELIVERY ROOM
Date and Focus Data, Action, Response
Time
From LR to DR D > Into delivery room ambulatory accompanied by RNSE / RMSE / SNOD /
IWOD on duty, with ongoing IVF of _________1L+_____ “u” oxytocin at
_____ ml level
infusing well at the R or L metacarpal/cephalic/basilic/ vein.
From Ward to LR
D > Into delivery room a _______ year old G__P__ mother from ER/OB
ward per wheelchair/stretcher/ambulatory accompanied by IWOD / RNSE /
RMSE on duty, with ongoing IVF of _____1L+ ___ “u” oxytocin at ____ml
level infusing well at the R or L metacarpal/cephalic/basalic vein.
For Direct DR
D > With full cervical dilatation and continuous uterine constractions
occuring 2 - 3 mins. and duration of 30-60 sec. , bloody mucoid and bulging
perineum noted.
Positioning and A > Assisted to DR table and positioned to dorsal lithotomy ; IE
Comfort done by
___________ revealing full cervical dilatation; administered oxygen
inhalation per
nasal cannula at 2-3 LPM; coached on proper bearing down.
A > RMLE done by Dr.___________/Perineal support done by
Dr._____________.
Safe delivery of the A > Delivered to an alive baby boy/girl via NSD in cephalic presentation with
baby a birth weight of _____kg and a birth length of ____cm attended by
Dr._______________.
Medication A > Oxytocin 1 amp. 10 units administered IM at R or L deltoid by NOD /
RNSE as
ordered
Start of Anesthesia A > Nubain 1 amp given intravenously by NOD / RNSE as per verbal
and Sedation order of
Dr._______________
A> Midozalam 1 / 2 / 1 amp. Given intravenously by NOD / RNSE as per
verbal
order by Dr.______________.
Safe delivery of A > Placenta out completely on Schultz / Duncan presentation; with BP of
placenta ____mmHg, PR of ______bpm, RR of ______cpm Temp.________°C
Medication A > Methylergine 1 amp. Administered IM / IV at R or L deltoid by NOD /
RNSE
as ordered
IV incoporation A > Addittion 10 “u” oxytocin to present IVF as per verbal order by
Dr.__________.
Episiorraphy A > Evacuation of blood clots and placental fragments done by
Dr._____________ using curette/manually; Episiorrhaphy done by
Dr.___________, massaged uterus until firm and contracted.
Post-partum care/ A > Transferred to stretcher then brought to LR; Advised to massage
Health teaching uterus until firm and contracted; to wash perineal area with tap water and
 to report excessive bleeding to NOD
Nutrition and Bonding > Breastfeeding initiated, bonding monitored, vital signs monitored and
recorded,
breast feeding per demand ans proper burping encouraged.
R > Delivered safely with minimal vaginal bleeding; with firm and
contractracted
uterus and with the latest vital signs of: BP_____mmHg, PR _____ bpn, RR
_____cpm, temp. _____°C
Unit transfer >Brought to OB ward per stretcher/ wheelchair accompanied by
_______________ and with ongoing IVF of ___________1L+_______”u”
oxytocin still at _______ml.

NURSERY
Date and FOCUS PROGRESS
Time
Immediate D > Born an alive baby boy/girl via NSD attended by Dr.__________________
newborn care •For private patients please include received by (Pediatrician)
•For babies from OR
D > Into DR from OR and alive babg boy/girl cuddled by Dr.______________.
With loud/weak cry, with 1 - 2 loose / tight cord loop, thin / thick meconium
stain, pinkish / acrocyanotic in color, caput succedaneum, with abundant / moderate
/ scanty vernix caseosa noted all over the body/back/buttocks/groin/armpits, with
moderate lanugo at
the back; with strong flexion and extension of extremities, with positive stool, APGAR
score
of _______, _____ at 1st and 5th minute respectively, with initial vital signa of
temp.____°C, CR_____bpm, RR_______cpm
Promoting A > Rendered immediate newborn care, placed on mother’s abdomen,
bonding, immediate drying of oronasal secretions and blood stain done, put on bonnet,
airway, and cord initiated bonding with mother
care with through skin to skin contact , cord cut aseptically when pulsations stopped ;
oronasal
secretions suctioned (if done).
> Administered oxygen inhalation via oxygen mask/ nasal cannula at 0.5-1 lpm
Data and A > Anthropometric measurements take are as follow: wt.________kg, L_______cm,
Identification HC___
___cm, CC ________cm, AbdC ________cm, ArmC________cm, clothed and
placed name tag on left foot, credes prophylaxis applied on both eyes and Vitamin
K 0.1 ml at left vastus
lateralis
Immunization A > Hepatitis B vaccine 0.5ml given at right vastus lateralis
A > Seen and examined by Dr._____________. (Pediatrician if seen)
Nutrition and A > Cleansed breast of mother, latching done with good/fair sucking reflex noted.
bonding R > Brought to OB ward beside mother per stretcher with latest vital signs of Temp.
____°C,
CR____bpm, RR_____cpm accompanied by_______________.
RECEIVING BABIES UNDER RADIANT WARMER
Immediate A > Received an alive baby boy / girl under radiant warmer with ongoing
newborn care oxygen per nasal cannula at ________ lpm, with loud / weak cry, pinkish /
acrocyanotic ,
with initial vital signs of Temp. _______°C, CR _____ bpm RR _____ cpm. Nasal
flaring /
grunting / clubfoot.
A > Promoted safety by putting pillows at the side, monitored vital signs and
recorded
(more interventions)
Nutrition and A > Latching done to mother at PACU with good/fair sucking reflex.
Bonding A > Roomed in to mother at OB ward with latest vital signs of Temp. _____°C; CR
_____bpm; RR______cpm cuddled by___________________.