Triage Notes for Patient Anna
Patient Presentation
- Patient Name: Anna
- Accompanied by: Husband, Lewis
Triage Details
- Time of Arrival: Approximately 30 minutes prior to evaluation
- Contractions:
- Start Time: Around 0200 hours
- Frequency: Every 5 minutes
- Duration: Lasting about 40 seconds
- Sleep Impact: Unable to sleep through contractions
Gestational Age
- Gestational Age: 39 weeks and 5 days
Fetal Monitoring
- External Fetal Monitoring Results:
- Fetal Heart Rate: 130 bpm
- Reactivity: Positive reactivity
Obstetric History
- Gravida Status: Gravida 2 (G2)
- Previous Child:
- Age of Child: 3 years old
- Birth Details: Born at term
- Current Pregnancy: Uncomplicated
Current Labor Assessment
- Dilation: 5 cm
- Effacement: 90%
- Station: -1
- Cervical Findings: Bulging bag of waters
Previous Labor Details
- Labor Duration: Approximately 8 hours
- Pain Management Preference: Would like to try without pain medication
Baby's Gender
- Gender Status: Unknown; they don't know the gender yet
Breastfeeding Plans
- Previous Experience: Breastfed their oldest child
- Plan for Newborn: Would like to breastfeed again
Infectious Disease Status
- Group B Streptococcus (GBS): Negative
- Rubella Immunity: Not immune
- Blood Type: A positive
- Attending Physician: Dr. Amister
- Aware of Arrival: Yes
- Estimated Time of Arrival: About one hour
- EHR Notes: Admission orders are in EHR
Dietary Preferences
- Cultural Considerations: Patient family keeps kosher
- Meal Arrangements:
- Specific dietary needs not required at this time
- Option to bring meals from home if needed
Postpartum Plans
- Length of Stay: They do not plan on staying long after the baby is born.