OB Admission Checklists & Dot Phrases

After a Delivery:

• •Add to Postpartum list.
• •Delivery note — access through delivery summary tab.
• •Postpartum orders: OB Post Vaginal Delivery order set. Reconcile orders under “Transfer” tab using postpartum order set.
• •Update Handoff with delivery info.
• •Start Discharge summary — speed button in DUH IP OB context “OB Discharge”. Share once started.
• •Add patient to your personal ACGME Log list.
• •Complete VTE risk calculator.
• •Delivery summary tab — lowest priority; ideally completed by end of shift but can do next day.

Admitting an Antepartum patient:

• •Staff with upper level.
• •Sign H&P.
• •Add to Antepartum list.
• •Start Handoff — .OBAPSIGNOUT2018
• •Admission orders: OB Antepartum Admission order set. Use “Admission” tab.
• •Ask if patient needs scan and/or CS consent.
• •Tubal consent (consider for preterm patients).
• •Communicate to Antepartum team.

Admitting an Active patient:

• •Staff with upper level.
• •Sign H&P.
• •Add to Active list.
• •Communicate to Active team and Charge RN.
• •Write Handoff (if not already drafted) — .OBHANDOFF*** phrases.
• •Admission orders: OB Labor and Delivery Admission order set. Check GBS status and history of HSV.
• •Write labor sheet. Scan for presentation. Ask if patient needs CS or TOLAC consent.

Discharging someone from triage:

• •Staff with upper level.
• •Discharge orders — use “Discharge” tab.
• •Discharge instructions — .TRIAGEPRECAUTIONS
• •Ensure patient has follow-up appointment scheduled. Communicate plan to patient and triage nurse.
• •Sign H&P.

OB Dot Phrases Reference: