Documentation Guidelines

• Vital signs: BP (value and patient's position); heart rate; daily weights; intake and output

• Edema: Location, presence or absence of pitting, numerical rating (1 to 4)

• Reflexes rated on a 1 to 4 scale and presence or absence of clonus

• Presence or absence of headache, visual disturbances, altered sensorium, epigastric discomfort, nausea

• Response to treatment: Anticonvulsants, antihypertensives, sedatives, bedrest

• Fetal assessment: Baseline heart rate; presence or absence of accelerations, decelerations, variability, fetal movement; response to movement

• Patient's response to pain during labor and to pain relief measures (analgesics, epidural)

Premature Rupture of Membranes 763

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