Postpartum Assessment Example Form PDF Details

Giving birth is an amazing and overwhelming experience, both physically and emotionally. The weeks following delivery can present numerous physical changes for the new mother, which can make postpartum assessments a necessity for their health and wellbeing. To help address these changes in a timely manner, healthcare providers or midwives may use dedicated postpartum assessment forms to check on the progress of their patients throughout the recovery period. In this blog post we will explore one example form to better understand what type of factors are evaluated during this process.

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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