Obstetric Triage Evaluation Note

Date/Time: [Date and time of triage arrival and provider evaluation]
Patient: [Patient name and identifier per local policy]
G/P: [Gravida/Para notation]
Gestational Age: [GA with EDD, dating method, and source] (If unknown at arrival, state "GA unknown at presentation; dating source pending.")

Chief Complaint

[Chief complaint in one line] (Patient quotation acceptable.)

Triage Acuity & Initial Assessment

Acuity: [Triage level per local scale] — [Brief rationale]
Initial Maternal Vitals: BP [value] | HR [value] | RR [value] | Temp [value] | SpO2 [value] | Pain [0–10]
Immediate Fetal Assessment: [Doppler FHT with rate / EFM initiated at time] — [Initial impression]
Immediate Actions: [Actions taken prior to full evaluation with timestamps] (Include IV access, labs sent, protocols activated.)

Pregnancy Summary

• Prenatal care: [Provider/clinic] — [Records available / partial / unavailable]
• Gestation: [Singleton / Multiple] — [Presentation if known]
• Complications this pregnancy: [GDM / chronic HTN / preeclampsia / placenta previa / FGR / other / none]
• Blood type/Rh/Antibodies: [Type, Rh, antibody screen] (State "unknown" with source attempted if unavailable.)
• GBS status: [Positive / Negative / Unknown] — [Date if known]
• Prior uterine surgery: [None / Prior cesarean with number and type / Other] (Include if labor is a concern.)

History of Present Illness

[Narrative beginning with chief complaint: onset, duration, frequency, severity, quality, progression, modifying factors, and context specific to presenting concern. Include relevant prior evaluations or treatments today.] (If history limited by pain, mental status, or language barrier, document limitation and collateral source.)

Fetal movement: [Normal / Decreased / Absent — last perceived time]
Vaginal bleeding: [None / Present — amount and pattern]
Leakage of fluid: [None / Present — characteristics]
Contractions: [None / Present — frequency, duration, change over time]

Review of Systems

[Focused ROS pertinent to presentation] (Do not repeat HPI. Include additional positives with brief clarification; list key negatives only when decision-making is affected.)

Pertinent History

• Obstetric: [Prior pregnancies with outcomes and complications relevant to current presentation]
• Medical/Surgical: [Conditions impacting triage decisions]
• Medications: [Current medications] (Note last dose timing for insulin, antihypertensives, anticoagulants.)
• Allergies: [Allergen] — [Reaction type]
• Social: [Tobacco/alcohol/substance use; safety concerns if pertinent]

Physical Examination

• Vitals: BP [value] | HR [value] | RR [value] | Temp [value] | SpO2 [value] (Repeat and document trends if abnormal or disposition-dependent.)
• General: [Appearance, distress level, mental status]
• Cardiovascular: [Findings] (Include if symptomatic or abnormal vitals.)
• Pulmonary: [Findings] (Include if respiratory symptoms present.)
• Abdomen/Obstetric: [Gravid uterus, tenderness, peritoneal signs, uterine tone, palpated contractions, fetal position by Leopolds if assessed]
• Extremities: [Edema; calf tenderness if VTE concern]
• Neurologic: [Reflexes and clonus] (Include if hypertensive disorder considered.)

Pelvic Examination

(Include when performed for labor assessment, ROM evaluation, or bleeding workup. If not performed when expected, state "Pelvic exam not performed — [reason].")

• Chaperone: [Name and role] (If declined or not feasible due to emergency, state rationale.)
• Exam type: [Sterile speculum / Digital cervical / Bimanual]
• Speculum findings: [Discharge/bleeding, pooling present or absent, cervical appearance]
• Cervical exam: [Dilation] / [Effacement] / [Station] — [Presenting part] — Membranes [intact / ruptured / uncertain]
• If digital exam deferred: [Reason and alternative evaluation performed]

Fetal Assessment

• Method: [Doppler / Continuous EFM / Intermittent auscultation] — [Start time] to [End time]
• EFM interpretation (NICHD): Baseline [rate] | Variability [absent / minimal / moderate / marked] | Accelerations [present / absent] | Decelerations [none / variable / late / early / prolonged — recurrent yes/no] | Category [I / II / III]
• Uterine activity: Contractions q[frequency] min | Tachysystole [present / absent]

Ultrasound

(Include only if performed.)

• Indication: [Reason for ultrasound]
• Technique: [Bedside limited / Formal study]
• Findings: [Fetal cardiac activity, presentation, placental location, amniotic fluid assessment, BPP components if applicable]

Diagnostic Testing

(Include collection times; flag abnormal values.)

• ROM testing: [Pooling / Nitrazine / Ferning / Immunoassay] — [Interpretation] (Note confounders if present.)
• Urine: [UA/culture results]
• CBC/Coagulation: [Results with abnormal flags]
• Hypertensive labs: [LFTs, creatinine, platelets, urine protein] — [Results]
• Infectious workup: [Tests and results]
• Other: [Additional diagnostics]
• Pending: [Tests pending] — Notification plan: [How/when patient notified] — Impact: [Whether pending results may change plan]

Treatments & Interventions

• Medications/Fluids: [Medication, dose, route, time] — [Response]
• Procedures: [Procedures beyond routine] — [Outcome]

Clinical Course

(Include only if observation or serial reassessment occurred.)

• [Time] — [Event, exam finding, or monitoring change]
• [Time] — [Event, exam finding, or monitoring change]

Assessment

(Problem-oriented, highest acuity first. Use "confirmed" only with objective criteria met; "suspected/possible" when evaluation incomplete.)

• [Problem 1]: [Diagnosis or rule-out with key supporting data]
• Maternal status: [Stable / Unstable — key vitals and symptoms]
• Fetal status: [Reassuring / Nonreassuring — category and key features]
• [Problem 2]: [Diagnosis or concern with key data]

Plan

• [Problem 1]: [Further evaluation/monitoring; medications/interventions; consults; counseling and patient preferences]
• [Problem 2]: [Plan elements as above]

Disposition

Disposition: [Discharge home / Admit to (service and level) / Transfer]
Condition at Disposition: Maternal — [Stability summary]; Fetal — [Status summary]
Follow-up: [Timeframe and provider]
Return Precautions: [Specific to presenting complaint: labor signs, ROM concerns, bleeding thresholds, decreased fetal movement, preeclampsia warning signs, fever, worsening pain]
Communication: [Interpreter use if applicable; patient understanding confirmed]

For transfers: Reason — [Clinical indication]; Stabilization — [Interventions performed]; Accepting — [Facility and provider]; Transport — [Mode and level]

(For high-stakes items—GA, Rh status, GBS status, placenta location in bleeding—explicitly document "unknown" with source attempted rather than leaving blank. If an expected exam was not performed, document "not assessed — [reason].")