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Admission clerking template

What to write when you admit a pregnant woman.

Source: Good practice

Write in this order

  1. Date, time, your name and grade.
  2. Name, age, hospital number, gravida/para, gestation (LMP and dating scan), EDD, booked or not.
  3. Presenting complaint and history.
  4. This pregnancy, previous pregnancies, medical and surgical history, drugs, allergies, blood group.
  5. Observations (MEOWS), general and abdominal examination, CTG, vaginal findings with consent.
  6. Impression or differential.
  7. Plan: investigations, treatment, monitoring, who was informed, when to review.
  8. Sign, print name, bleep or contact number.
A summary for trained clinicians. Always check the full guideline, the patient in front of you and your hospital's protocol. Spotted an error? Tell us.