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Prenatal Assessment

  • Updated

The Details Tab
The Referral Tab
The History Tab
Assessment Tab
Teaching and Support Tab
Nursing Priority Screening Tab
Document Upload Tab

See the Prenatal Assessment Guideline for more information.

  • This document is what guides PHN documentation in PARIS
  • It gives instructions about how to chart in PARIS
  • It differs from the Prenatal Nursing Care Path which guides practice
  • The Prenatal Nursing Care Path helps to determine what to assess and what actions to take

Clinical Directives:

  • Page 1- Reminds the PHN to use nursing judgment to determine which categories will be assessed and whether a concern or variance exists

The Prenatal Assessment has 6 tabs

The 6 tabs are located at the bottom of the form as showed below and are Details, Referral, History, Assessment, Teaching And Support, & Document Upload:

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The Details Tab

The Details tab is the same as all the other Details tabs. In the Header Details Section:

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1. Enter the following fields:

  • Date started: Enter the start date of the Assessment (shortcut for today’s date = Ctrl-T). PARIS date format: DD/MM/YYYY
  • Team: Your tean defaults in
  • Carried out by: The logged on users name defaults in

The Referral Tab

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  • The Referral Tab can be completed by a PA or a PHN. It reflects information obtained from the referral source either on the faxed referral form or during a conversation at the time of referral. PA will transcribe what is on a written form.
  • Expected date of birth as per the referral form.
  • Use the Comment section if referral information is not covered by options above or if additional information is provided.
  • Universal screening-this field is not currently being used. **leave blank
  • Pregnancy questionnaire- If the PHN completes an Intake Interview, tick this. May also be used if a paper prenatal questionnaire is received in Richmond, North Shore or Fraser Health.
  • If yes, the next question requires an answer.
  • Method of contact- refers to how does the client prefer to be contacted?
  • Comment section-for additional information prn.
  • Tick section complete for name to appear and then it locks this tab.

The History Tab

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  • Completed by the PHN within the first couple of contacts.
  • Consider it a snapshot in time.
  • Many of the fields in this tab are NFP mandatory, but they are not PHN mandatory.
  • There are only 2 fields that are mandatory. They are the expected date of delivery (EDD) and the pregnancy type (single/twin/multiple). Without completing EDD, PHN cannot save the assessment tab. Therefore, PHN can estimate the EDD as required. If the EDD is saved, and at a later contact, PHN receives information EDD has changed by >1 week, end date current assessment and create a new Prenatal Assessment with correct EDD.
  • These fields are mandatory because they trigger functionality on the assessment tab, such as calculating number of weeks gestation.
  • The other fields that trigger functionality are the weight and height fields.
  • Pre-pregnant height and weight are related to being able to assess and/or monitor weight gain throughout the pregnancy. It is unlikely that as a 0-5 PHN will be doing this, but the weight monitoring functionality was included to allow HBP team members to utilize the same assessment form. Although the HBP team may use the same assessment form they will be doing so under the HBP team not the ICY team.
  • PHNs should complete the information in the history field that they feel is clinically relevant to the care they are providing to the client. For example: If the client has recommended medical follow up and has no concerns re: management of acute or chronic illness PHN will use clinical judgment when completing the health history, STI or UTI questions.
  • However, PHN may be interested in the answers to the BF questions and assessing the client’s needs around infant feeding.
  • Some of the information (such as the immunization status) may or may not be collected as part of PHN early assessments depending on clients needs and priorities. Updates of information can be included in assessment and casenotes at later dates.
  • PHN can save without ticking section complete and this will allow the nurse to go back in and add information, but when ticking section complete, PHN is responsible to ensure the accuracy of all the information in the tab.
  • Once the fields are entered and marked ‘Section Complete’, they cannot be changed and if there are adjustments, such as the mom is having twins, this assessment will need to be end dated and a new assessment created.
  • The fields that will need to be completed on the new assessment will be the expected date of delivery and the pregnancy type. DO NOT USE Copy assessment.
  • PHN name and date will only auto-populate if Section Complete is ticked.

Assessment Tab

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  • Number of weeks gestation will auto-populate from EDD field in history tab.
  • Assessment items are like those in Maternal or Newborn assessment forms. The drop down box indicates whether PHN has: X not assessed, NC assessed no concern, or C for a variance (remember variance is according to the prenatal pathway)
  • The difference between this assessment and others used in Public Health is that there is no anticipatory guidance built into this assessment form.
  • The weight gain is the only additional section with any functionality.
  • Remember to tick ‘Column Complete’ at the bottom to save.

Teaching and Support Tab

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  • This is where PHN documents resources given or external referrals made on an ongoing basis.
  • The items in the picklist are broad, but can be added to.

Document Upload Tab
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  • When clicked, the Guidance note button located under the section header provides additional information on which forms the files you upload to the Prenatal assessment will be visible in.

For information on how to use the Document Upload tab, see Document Upload (PH).