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Date____________________
Student’s Name____________________
POST PARTUM DATA COLLECTION SHEET
Maternal Information
Patient Initials_______ Rm#________ Age_____ Ethnicity____________Primary Language_____________
Religion__________
Marital Status________ Support Person(s)_________________ Cultural Issues________________________
G__T__P__A__L__ Ages of Children_____________
EDD ________ Delivery Date & Time___________Method of Delivery _________Anesthesia________
Laceration/Episiotomy_____________
Complications of Pregnancy and/or Delivery
___________________________________________________________________________________
Complications of
Postpartum__________________________________________________________________________
Allergies________________
Labs: PP Hgb/Hct_________ ABO/Rh_______ Rubella________ Hepatitis B_____ GBS______
Other_______
Treatments & Procedures
Medications/IVs
Previous Shift Report Shift Assessment
Baseline Vitals_____________ Baseline Vitals_____________ Maternal Phase_____________
PP Assessment _____________ Heart and Lungs____________ Maternal/Infant Interaction
Diet______________________ Breasts____________________ __________________________
Voiding___________________ Uterus____________________ Personal Hygiene/Self-Care
Activity Level______________ Bowel____________________ __________________________
Time of Last Pain Med_______ Bladder___________________ Self-Concept_______________
Emotional State_____________ Lochia____________________ Recall of Birth______________
Mother/Infant Interaction Episiotomy(perineum)_______ Involvement of Partner_______
__________________________ Homan’s__________________ Support System_____________
Priority Client Needs_________ Emotions__________________ Plan for Home Care_________
Activity___________________ Cultural Issues______________
Rest/Comfort_______________ Stability of Patient Condition
Hydration_________________ _________________________
Teaching Needs Priority Client Needs
Planned: Actual:
1
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SMU - Internal Data
M*&!#%#&&!%%#^#^&^!#&*^&^*#!(FG*T!^&*#*((*!#&()#_)#!*&$!*#)(!*##(*0Postpartum_worksheet.docx.pdf*&!#%#&&!%%#^#^&^!#&*^&^*#!(FG*T!^&*#*((*!#&()#_)#!
*T!^&*#*((*!#&()#_)#!*&$!*#)(!*Postpartum_worksheet.docx10/16/2026,
Page 1 of 210/16/2026, 5:42:03 AM*&!#%#&&!%%#^#^&^!#&*^&^*#!(FG*T!^&*#*((*!#&()#_)#!*&$!*#)(!*Postpartum_worksheet.docx10/16/2026,
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stpartum_worksheet.docx10/16/2026,
Page 1 of 210/16/2026, 5:42:03
5:42:03
AM*&!#%#&&!%%#^#^&^!#&*^&^*#!(FG*T!^&*#*((*!#&()#_)#!*&$!*#)(!*Postpartum_worksheet.docx10/16/2026,
AM*&!#%#&&!%%#^#^&^!#&*^&^*#!(FG*T!^&*#*((*!#&()#_)#!*&$!*#)(!*##(*0Postpartum_worksheet.docx.pdf*&!#$$$$
5:42:03 AM*&!#%#&&!%%#^#^&^!#&*^&^*#!(FG*T!^&*#*((*!#&()#_)#!*&$!*#)(!*##(*0Postpartum_work
5:42:03 AM*&!#%#&
Date____________________
Student’s Name____________________
POST PARTUM DATA COLLECTION SHEET
Maternal Information
Patient Initials_______ Rm#________ Age_____ Ethnicity____________Primary Language_____________
Religion__________
Marital Status________ Support Person(s)_________________ Cultural Issues________________________
G__T__P__A__L__ Ages of Children_____________
EDD ________ Delivery Date & Time___________Method of Delivery _________Anesthesia________
Laceration/Episiotomy_____________
Complications of Pregnancy and/or Delivery
___________________________________________________________________________________
Complications of
Postpartum__________________________________________________________________________
Allergies________________
Labs: PP Hgb/Hct_________ ABO/Rh_______ Rubella________ Hepatitis B_____ GBS______
Other_______
Treatments & Procedures
Medications/IVs
Previous Shift Report Shift Assessment
Baseline Vitals_____________ Baseline Vitals_____________ Maternal Phase_____________
PP Assessment _____________ Heart and Lungs____________ Maternal/Infant Interaction
Diet______________________ Breasts____________________ __________________________
Voiding___________________ Uterus____________________ Personal Hygiene/Self-Care
Activity Level______________ Bowel____________________ __________________________
Time of Last Pain Med_______ Bladder___________________ Self-Concept_______________
Emotional State_____________ Lochia____________________ Recall of Birth______________
Mother/Infant Interaction Episiotomy(perineum)_______ Involvement of Partner_______
__________________________ Homan’s__________________ Support System_____________
Priority Client Needs_________ Emotions__________________ Plan for Home Care_________
Activity___________________ Cultural Issues______________
Rest/Comfort_______________ Stability of Patient Condition
Hydration_________________ _________________________
Teaching Needs Priority Client Needs
Planned: Actual:
1
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SMU - Internal Data
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*T!^&*#*((*!#&()#_)#!*&$!*#)(!*Postpartum_worksheet.docx10/16/2026,
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