Postpartum Assessment Example Form PDF Details

The Postpartum Assessment Example Form is a vital tool within the Comprehensive Perinatal Services Program, designed to guide healthcare providers in conducting thorough postpartum evaluations. This detailed form encompasses various elements crucial for assessing the well-being of both the mother and the newborn, subsequent to delivery. Key areas of assessment include anthropometric measurements, such as height, body weight goals, and postpartum weight, which offer insights into the physical recovery of the mother. Biochemical data, including hemoglobin and glucose levels, provide information on the mother's post-delivery health status. Furthermore, the form captures significant pregnancy and delivery details, including the outcome of the pregnancy, any complications, and the type of delivery, alongside the newborn's health metrics such as birth weight and current measurements. The form delves into maternal and infant nutrition, addressing dietary assessments and feeding methods, which are crucial for both mother and child's well-being. It also explores psychosocial aspects, inquiring about the mother’s emotional state, adjustments within the household, and the support system available for the new family. Additionally, healthcare referrals, educational needs, and a plan encompassing client goals and interventions are outlined. This comprehensive approach ensures that both the mother and the infant receive the care and support necessary during the critical postpartum period.

QuestionAnswer
Form NamePostpartum Assessment Example Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namespostnatal assessment formates, postnatal assessment format, postnatal assessment format pdf, postpartum charting template

Form Preview Example

COMPREHENSIVE PERINATAL SERVICES PROGRAM

COMBINED POSTPARTUM ASSESSMENT

Name:DOB: Date: I.D. No.

Health Plan:__________________ Provider: _________________ Delivery Facility: _________________

Anthropometric:

1. Height

 

2. Desirable Body

3. Total Pregnancy Wt.

 

4. Wt. this visit

 

 

Wt.

 

 

Gain

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5. Prepregnant wt.

6. Postpartum Wt.

 

 

7. Weeks Postpartum this

 

 

 

 

Goal

 

 

Visit

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Biochemical:

Blood:

Date Collected:

 

 

8. Hemoglobin:

(<10.5)

9. Hematocrit:

Urine:

Date Collected: ________________

10.

Glucose:

+

­

11.

Ketones:

+ ­

12.

Protein:

13.

Blood Pressure:

 

/

Comments:

 

 

(<32) Other:

+ ­ Other:

Clinical ­ Outcome of Pregnancy:

14. Date of Birth:

17.Birth

Weight:(gms)

19. Current Weight: (gms)

21. Type of Delivery: (circle) NSVD

15.

Gestational

 

16. Pregnancy/Delivery Complications:

Age:

 

 

 

 

 

 

 

 

 

 

 

 

18.

Birth Length (cm):

 

 

 

 

 

 

 

 

 

 

 

20.

Current Length(cm):

 

Apgar Scores: 1 min:

5 min:

 

 

 

 

VBAC Vacuum Forceps

C­Section ( Primary or Repeat )

( LTCS or Classical )

Maternal:

 

 

 

Infant:

 

 

 

22.

 

Have you had your postpartum check up?

�Yes

Date:

24.

Has infant

had a newborn check­up?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

�If No,

when scheduled?

 

 

 

 

 

 

If No,

 

when scheduled?

23.

 

Any health problems since delivery?

�Yes

 

�No

 

 

If Yes, any Problems?

 

 

If YES, please explain:

 

 

 

25.

 

Number of NICU Days:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

26.

 

Infant exposure to: (circle all that apply)

Nutrition:

 

 

 

 

 

 

 

 

 

 

Tobacco

Alcohol

Drugs

 

27. Maternal Dietary Assessment: For ____ Day(s)

 

Dietary Goals:

 

 

 

 

 

 

 

Servs./

 

Suggested

 

Client agrees to:

 

 

 

 

Food Group

 

Points

 

Change

 

 

 

 

 

 

 

 

Protein

 

 

+

­

 

 

 

 

 

 

 

 

 

 

 

Milk Products

 

 

+

­

 

 

 

 

 

 

 

 

 

 

 

Breads/Cereals/Grains

 

 

+

­

 

 

 

 

 

 

 

 

 

 

 

Vit. C­rich fruit/veg

 

 

+

­

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Vit. A­rich fruit/veg

 

 

+

­

 

 

 

REFERRALS:

� WIC

Date Enrolled: _________________

 

Other fruit/veg

 

 

+

­

 

 

 

� Food Stamps

� Emergency Food

� AFDC

 

 

Fats/Sweets

 

 

+

­

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Diet adequate as assessed:

� Yes

� No

Excessive:

 

� Caffeine

 

 

 

 

 

 

28. Infant

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Method of Feeding:

� Breast

� Bottle

 

 

� Breast & Bottle

 

# Wet diapers/day?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Type of Formula:

 

 

With Iron?

� Yes

 

� No

 

oz..

 

 

times/day

Psycho­Social

29.

Do you feel comfortable in your relationship with your baby?

� Yes

�No

 

Any special concerns?

 

 

 

 

30.

Are you experiencing post­partum blues?

�Yes

�No

 

31.

Have your household members adjusted to your baby?

�Yes

�No

 

32.

Has your relationship with the baby’s father changed?

�Yes

�No

 

33.Do you have the resources to assist in maximizing the

health of you and your baby?

 

�Yes

�No

 

If “No”, indicate where needs exist: �Housing

�Financial

�Food

�Family �

Other:

 

 

 

 

34.Outstanding issues from Prenatal Assessment/Reassessment:

Health Education

35. If breast feeding:

 

 

 

 

 

 

38. Do you have any questions about

 

 

 

 

 

 

Do you have enough milk?

 

 

�Yes

�No

 

 

 

your baby’s safety?

 

�Yes

�No

Do you supplement with formula?

�Yes

�No

 

 

 

If “Yes”, please explain:

 

 

 

 

 

 

Does your baby take the breast

 

 

�Yes

�No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

easily?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Are your nipples cracked and/or

�Yes

�No

 

39. Are you using, or planning to use, any method of

sore?

 

 

 

 

 

 

 

 

birth

 

 

 

 

 

 

Do you have any questions about

 

 

 

 

 

 

control?

 

�Yes

�No

 

breast feeding?

 

 

�Yes

�No

 

 

 

If “Yes”, which

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

one?

 

 

 

 

 

 

 

36. Do you have any questions about

 

 

 

 

 

 

If “No”, would you like further information?

 

 

 

mixing or feeding formula?

 

 

�Yes

�No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

37. Do you have any questions about your

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

baby’s health?

 

 

�Yes

�No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If “Yes”, please explain:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Plan:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Client Goals, Interventions and Timeline

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Client agree to:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Referrals

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Agency:

 

 

Date:

 

 

 

 

Agency:

 

 

Date:

 

 

 

 

Materials Given:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

�Birth Control

�___________

�Infant Feeding

�______________

�Infant Care

�___________

�Infant Safety

�___________

�

�________________________

Summary:

Date:

 

Interviewer:

 

Title

 

Minutes Spent:

Copy of Individualized Care Plan sent to Patient’s PCP on: (date) ______ by: (name and title)_______________________

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