Do you have an Advance Directive? YES: NO

ADVANCE DIRECTIVE ACKNOWLEDGMENT
Do you have an Advance Directive?
YES:
(Initial next to all that apply)
________
________
________
Living Will
Durable Medical Power of Attorney (DMPA)
CPR Directive/Physician Order required
Current location of above documents: _________
_________
_________
_________
On medical record
With patient
Family to bring in
Unable to obtain copy
If you do not have a copy with you, please state contents: ________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
Do you wish Valley View Hospital to honor the Advance Directive at this visit?
Please initial: __________ Yes
NO:
__________ No
If no, do you want information about Advance Directives? Please initial _______ Yes _______ No
VVH staff only: Check all that apply _________ Information given (Patient Rights brochure)
_________ Information given (Five Wishes)
VVH Staff Signature ___________________________________________________
VVH staff only:
N/A - Newborn or pediatric patient, hospice patient, reference lab patient, recurring Cardiac Rehabilitation
patient, Radiology Department outpatient
Patient unable to sign; referral to Case Management
Patient Signature
Date
ADVANCE DIRECTIVE
*ADM.ADACK*
Page 1 of 1
Rev. 12/12
Glenwood Springs, CO
Time
RECONOCIMIENTO DE INSTRUCCIONES PREVIAS
¿Tiene usted instrucciones previas?
SÍ:
(Escriba sus iniciales al lado de todo lo que corresponda)
________
________
________
Testamento vital
Poder notarial duradero para atención medica
Instrucciones para CPR/se requiere orden medica
Ubicación actual de los documentos anteriores: _________
_________
_________
_________
En el expediente medico
Con el paciente
La familia lo traerá
No pudo obtener copia
Si no tiene copia con usted, indique el contenido: _______________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
¿Desea que Valley View Hospital cumpla con las instrucciones previas en esta visita?
Escriba sus iniciales: __________ Si
NO:
__________ No
Si contesta no, ¿desea información sobre Instrucciones previas?
Escriba sus iniciales: _______ Si _______ No
Solo personal de VVH: Marque todas las que apliquen
_________ Se entrego información (folleto sobre Derechos del paciente o Patients Rights brochure)
_________ Se entrego información (Cinco deseos o Five Wishes)
Firma del personal de VVH/VVH Staff Signature ________________________________________________
Solo personal de VVH:
N/A - Paciente pediátrico o neonato, paciente de cuidados paliativos, paciente remitido de laboratorio,
paciente de Rehabilitación cardiaca recurrente, paciente ambulatorio del Departamento do Radiología.
El paciente no puede firmar; remitido a la oficina de Manejo de Casos
Firma del paciente
Feche
ADVANCE DIRECTIVE - SPANISH
*ADM.ADACKS*
Page 1 of 1
Rev. 12/12
Glenwood Springs, CO
Hora
Initial
Signature
Initial
SIGNATURE SHEET
*NUR.SIG*
Page 1 of 1
Rev. 02/12
Glenwood Springs, CO
Signature
MATERNAL ADMISSION ASSESSMENT SBAR
Family Birthplace
Before calling the Physician or CNM:
1. Assess the patient.
2. Read most recent notes
3. Have the chart in-hand
SITUATION
S
B
A
R




Identify yourself and where you are calling from.
Patient's name ________________________________________
Patient was admitted for: ____________________________________________
I am concerned about:
FHR
Contraction Pattern
Blood Pressure
Vaginal Bleeding etc.
BACKGROUND






Gravida ________ Para ______ at _____ weeks gestation.
OB or CNM attending ___________________________
Significant medical and obstetrical history includes: _____________________________
Problems with current preg. ________________________________________________
Patient is _____ cms, and her pain scale is _________
Check all term patients, unless they are actively bleeding. Do NOT check preterm
patients unless they look like they are going to deliver or instructed by provider.
ASSESSMENT
 Maternal Vital Signs ______________________________________________________
 FH = Variability, Baseline, Accelerations, Decelerations, Contraction Pattern, The FHR
tracing is a category _______.
 Significant Lab Values ___________________________________________________
 Intrauterine Resuscitative Measures
 Give your conclusions about the current situation. Words like "might be" or "could be"
are helpful.
RECOMMEDATION
 What I need from you is __________________________________________________
 Be specific about a time frame _____________________________________________
 Suggestions for test/treatments:
 PIH Labs, Ua, CMP, Magnesium Level Pitocin, coagulation Profile, antibiotics
Clarify
orders, vital sign frequency, under what circumstances to call back.

SBAR Report given to
Date
(provider) by
Time
*This form is part of the legal medical record
MATERNAL ADMISSION ASSESSMENT SBAR Family Birthplace
*NUR.SBAR*
Page 1 of 1 Rev. 03/11
Glenwood Springs, CO
RN (signature)
PHYSICIAN ORDERS
(If no check box appears by order, order will occur unless crossed off by physician)
ANTEPARTUM - DISCHARGE FROM FAMILY BIRTHPLACE (FBP)
Allergies (Allergias:)
Discharge (Alta:)
NKA (Ninguna conocida o)
Home (Hogar)
Bedrest (Descanso en cama)
Modified Bedrest (Descanso en cama modificado)
Other (Otro)
Follow up at: (Seguimiento en:)
A Center for Women's Care (384-2000)
A Woman's Place (928-7717)
Sopris Woman's Clinic (230-9078)
Women's Health Associates (945-2238)
Other (Otro)
Date
Time
In (En)
Days
Weeks and in _______ weeks
(Fecha)
(días)
(Semanas y en ____ semanas)
(Hora)
Other (Otro:)
Teaching: (Educación)
Diabetes teaching:
Fetal movement kick count
Pre-term Labor precautions
(Precauciones de parto
(Conteo de movimiento
(Educación de
prematuro)
fetal)
diabetes)
DISCHARGE MEDICATIONS (MEDICAMENTOS DE ALTA)
None prescribed (Ninguno recetado)
Medication name
(Nombre del medicamento)
Prenatal vitamins
(Vitaminas prenatales)
Brand
(Marca)
N/A
Dose
(Dosis)
1 tablet
(1 tableta)
Route
(Vía)
Mouth
(Por boca)
Iron
Fer-In-Sol
(Hierro)
Stool softener
Surfak/Colace
(Ablandador fecal)
Acetaminophen
Tylenol
(Acetaminofén/Paracetamol)
Mouth
(Por boca)
Mouth
(Por boca)
Mouth
(Por boca)
Procarida
(Procardia)
Mouth
(Por boca)
Nifedipine
Frequency
(Frecuencia)
Daily
(Diaria)
Care Provider signature
Faxed by
Orders noted: RN Initial
Date/Time
to Care Provider:
Date/Time
Original to Chart
Copy to Patient
PO ANTEPARTUM DISCHARGE ORDERS
Family Birthplace
*PO.ORDER*
Hypertension (high blood pressure)
(Hipertensión)
Page 1 of 1
Rev. 02/12
Glenwood Springs, CO
Last dose/Date/Time
(Última dosis/Fecha/Hora)
PHYSICIAN ORDERS
(If no check box appears by order, order will occur unless crossed off by physician)
FBP - OUTPATIENT ORDERS
* Pharmacy Mnemonic - FBPOP
Allergies/Adverse Reactions: NKA or
Admit to:
Clinic
Observation
NURSING
1. Notify physician/CNM if:
a. Pulse less than 50 or greater than 120
b. Respiratory rate less than 8 or greater than 30
c. Blood pressure: Systolic less than 80 or greater than/equal to 160; Diastolic less than 45 or greater than/equal to 110
d. Temperature greater than 100.4º on 2 subsequent checks.
2. Medical indication:
Decreased fetal movement
Diabetic / GDM
Elevated BP
PTL
IUGR
SROM evaluation
Multiple gestation
Labor evaluation
Other __________________________________________________________________________________________
3. Procedure:
NST
EFM (Maternal Evaluation)
Serial blood pressures
Other __________________________________________________________________________________________
4. Labs:
CBC
Urine for protein
Other _________________________
PIH labs
UA culture if indicated
Other _________________________
MEDICATIONS
1.
Start IV: a.
LR
D5LR
Other _________________________________
b. Rate: _______________ mL/hour
c. May use Pain Adjunct for Venipuncture:
1) 0.05 mL-0.2 mL 1% buffered or plain Lidocaine intradermally at venipuncture (13 years or older)
2) Lidocaine cream at venipuncture site (12 years or younger or any age if indicated due to skin condition)
RN: Complete if telephone or verbal order
T/O or V/O Dr/CNM: _________________________________________________ / ________________________________
Care Provider
RN
Orders verified: RN Initial __________ Date/Time ___________________________
Care Provider signature _________________________________ Date _______________ Time _____________
Entered by: Initial _______ Date/Time _____________________
Sent to Pharmacy
Orders notes: RN Initial ________ Date/Time ___________________
RN: Complete if telephone or verbal order
T/O or V/O Dr/CNM: _________________________________________________ / ________________________________
Care Provider
RN
Orders verified: RN Initial __________ Date/Time ___________________________
Care Provider signature _________________________________ Date _______________ Time _____________
Entered by: Initial _______ Date/Time _____________________
Sent to Pharmacy
Orders notes: RN Initial ________ Date/Time ___________________
OUTPATIENT ORDERS - FBP
*PO.ORDER*
Page 1 of 1
Rev. 10/11
Glenwood Springs, CO
PHYSICIAN ORDERS
(If no check box appears by order, order will occur unless crossed off by physician)
FBP CLINIC STANDING ORDERS
Admit to:
Clinic
Medical indication:
Decreased Fetal Movement
Multiple gestation
IUGR
Diabetic/GDM
Preterm Labor
SROM evaluation
Labor evaluation
Other: ______________
NURSING
1. If patient has no prenatal care, call provider on call immediately
2. Assess patient that has established care and call provider with assessment for further orders
3. Fetal heart rate monitoring on admission and then per protocol
4. Monitor uterine contractions per protocol
5. Up ad lib unless indicated by Fetal Heart Rate (FHR) tracing
6. Vital signs per protocol
7. Notify physician if:
a. SBP less than 80 mmHg, greater than 160 mmHg
b. Heart Rate less than 50 bpm, greater than 120 bpm
c. RR less than 6 breaths/min, greater than 30 breaths/min
d. Temperature less than 97 degrees F (36.1° C), greater than 100.4 degrees F (38° C)
Care Provider Signature
Date
Entered by: Initial ___________ Date/Time ____________________
Orders noted: RN Initial ___________ Date/Time __________________
FBP CLINIC STANDING ORDERS
*PO.ORDER*
Page 1 of 1
Rev. 11/12
Glenwood Springs, CO
Elevated BP
Time
DATE/TIME
NOTES SHOULD BE SIGNED BY PHYSICIAN OR NURSE
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PROGRESS NOTES
*PN.PROGN*
Page 1 of 1
Rev. 06/10
Glenwood Springs, CO