Data best 2025 updated comprehensive
Focused Exam: Non-Reassuring Fetal Status - Objective Data
Patient Name: [Insert Name]
Date of Exam: [Insert Date]
Primary Physician: [Insert Name]
Gestational Age: [Insert Weeks]
Presenting Complaint: [Decreased Fetal Movement, Abnormal FHR Tracing, etc.]
Assessment Findings:
• Maternal Vital Signs:
o Temperature: [Insert] °F/°C
o Heart Rate: [Insert] bpm
o Blood Pressure: [Insert] mmHg
o Respiratory Rate: [Insert] breaths/min
o Oxygen Saturation: [Insert] %
• Fetal Monitoring:
o Fetal Heart Rate (FHR): [Insert] bpm
o Variability: [Absent/Minimal/Moderate/Marked]
o Accelerations: [Present/Absent]
o Decelerations: [Early/Late/Variable/Prolonged]
o Contraction Pattern: [Frequency, Duration, Strength]
o Category of FHR Tracing: [Category I/II/III]
• Ultrasound Findings (if applicable):
o Amniotic Fluid Index (AFI): [Insert] cm
o Biophysical Profile (BPP) Score: [Insert]
o Fetal Movement: [Normal/Reduced/Absent]
o Doppler Studies (if indicated): [Findings]
• Additional Clinical Signs:
o Meconium-Stained Amniotic Fluid: [Yes/No]
o Uterine Hyperstimulation: [Yes/No]
o Signs of Maternal-Fetal Distress: [Specify]
Interventions and Management:
• Positioning: [Left Lateral/Trendelenburg/etc.]