Dr. Balby writes the following note: Onset of contractions started at 4:00 a.m. Patient refused medications. Normal presentation. Outcome of delivery: single male infant. This information would be documented as part of the:
A) antepartum record
B) labor and delivery record
C) prenatal record
D) postpartum record
Question 2
Dr. Jones reviews the following information located in the patient record. In which report is the information documented?
Date
1/2/YYYY
1/3/YYYY
1/4/YYYY
1/5/YYYY
1/6/YYYY
1/7/YYYY
Blood Pressure
130/75
128/78
120/75
130/80
135/80
130/78
Temperature
99.3
99.5
99.8
99.5
99.8
99.9
Weight
139
139
137
137
136
138
A) history of present illness
B) physical examination
C) nursing care plan
D) vital signs record