Document Code No.

CHS/BSN-CURR -RLEFORM-003e
Revision No. Effective Date Page No.
00 02.24.2023 1 of 1

OB History

Patient’s Name: _______________ Age: ________ Date Admitted: ___________

Date and Time of Delivery: _____________________________________________
Diagnosis: __________________________________________________________

LMP: _______________ EDC: ______________ AOG: ___________________

FH: ___________________ FHT: ___________________

OB SCORE:
G (gravida) = ____________ A (abortion) = ___________
T (term) = ____________ L (living) = ___________
P (premature)= ____________

Place of Manner of
Gravida AOG Presentation Complications
Confinement Delivery
G1

G2

G3

G4

G5

EVALUATION TOOL: OB HISTORY FORM

UNACCEPTABLE SATISFACTORY EXCEPTIONAL REMARK
(1) (3) (5) S
Required The student does not The student provides some of The student provides all of the
Information provide the patient’s data the required information patient’s complete information

Proper Calculation The student records less The student records at least 4 The student records all correct
of Dates and than 3 correct answers correct answers answers
Measurement
OB Scoring The student checks less The student checks at least 5 The student checks all 6 correct
than 5 correct answers correct answers answers
GTPAL Evaluation The student records and The student records and The student records the history
evaluates assessment evaluates assessment with correctly
incorrectly little error
Performance & No aspect of work meets Has minimal aspects of work Has all the aspects of work that
Evaluation Tasks the level of expectation that meet the level of exceed the level of expectation
Has errors, omissions, and expectation Shows exemplary performance,
misconception With some errors and mastery confidence, and understanding
Approach to examination is not thorough Approach to examination was
was not organized and Approach to examination was organized and systematic
systematic satisfactory
Total ___/25