Antepartum / Intrapartum ISBAR and Clinical Learning - Direct Patient Documentation

I-SBAR FOR DIRECT PATIENT CARE DOCUMENTATION ANTEPARTUM/INTRAPARTUM

I Introduce yourself

Your Name: Your Title: Reason for being there:

D#:

S Situation

Patient Initials:

EDC: LMP: Other:

Singleton Twin Other

Reason for Admit:

Fetal Movement: Present

Membrane Status: Intact

Age: G____T____P____A____L____

Gest. Age: /7 weeks

Not Present:

Ruptured Date Time: Fluid:

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

Vital Signs

Labor status: onset: stage /phase:

Vaginal exam: _____/______/______ Blood/fluid ____________________

Planned method of delivery: vaginal c/section

Fetal heart rate pattern: reassuring non-reassuring

Contraction pattern: frequency duration strength

Labor progress:

Maternal physical assessment:

IV: CURRENT MEDS:

Labs:

Activity:

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.

12-200085 ©2020 Chamberlain University LLC. All rights reserved. 0420culcpe

YEAR TYPE OF DELIVERY LABOR LENGTH COMPLICATIONS

TEMP B/P HR RR SP02 PAIN FHTS

I-SBAR FOR DIRECT PATIENT CARE DOCUMENTATION ANTEPARTUM/INTRAPARTUM

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.

NR327_ ISBAR PP-NB_DirectPatientCare Documentation_V1 New: Nov19

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