| Course | PA 620 Clinical Clerkship - Obstetrics & Gynecology |
|---|---|
| Week | 2 |
| Paper type | Obstetric triage note |
| Length | About 490 words, 5 pages |
| Format | APA 7 student paper |
| School | Chamberlain University |
| Program | Master of Physician Assistant Studies (MPAS) |
| Updated | October 2026 |
Free sample paper for PA 620 Week 2
Obstetric Triage Note for A.B. at 39 Weeks 1 Day: Leaking Fluid Since 02:40, the Caller's Words Then Mine, Negatives Written as Findings, Times on Onset, Arrival and Examination and a Plan Named for the Next Clinician
Student Name
Chamberlain University
PA 620: Clinical Clerkship - Obstetrics & Gynecology
Instructor Name
Month Day, Year
Obstetric Triage Note for A.B. at 39 Weeks 1 Day: Leaking Fluid Since 02:40, the Caller's Words Then Mine, Negatives Written as Findings, Times on Onset, Arrival and Examination and a Plan Named for the Next Clinician
Written Before the Outcome
Labor and delivery triage, April 9, 2026. Note written at 03:55, before any decision about admission.
The Patient's Words, Then Mine
A.B., 29, G2P1, at 39 weeks 1 day by first-trimester ultrasound. In A.B.'s words: "I woke up at twenty to three and my pajamas were soaked. It's still trickling when I stand up. It's clear." Contractions: "Some tightening, maybe every ten minutes, not painful."
Times on Three Things
Onset of leaking: 02:40 (A.B.'s report). Arrival in triage: 03:10. Sterile speculum examination: 03:30.
The three times matter for different reasons. The onset time starts the clock on infection risk after rupture. The arrival time shows how long A.B. waited before coming in. The examination time shows when the diagnosis was actually made, which is the time the plan should be measured from.
Findings
Vital signs 03:15: temperature 36.8 °C, pulse 82, blood pressure 118/74.
Fetal heart rate tracing 03:15 to 03:45: baseline 135, moderate variability, accelerations present, no decelerations; category I.
Tocometry: contractions every 8 to 12 minutes, mild to palpation.
Sterile speculum examination 03:30: pooling of clear fluid in the posterior vagina; nitrazine positive; ferning seen on microscopy. Cervix visually about 2 centimeters dilated. No digital examination performed.
Group B streptococcus: negative at 36 weeks 3 days (prenatal record).
Pregnancy dating and history: 39 weeks 1 day by a 9-week ultrasound; first pregnancy a vaginal birth at 40 weeks without complications; no hypertension or diabetes in this pregnancy; no allergies.
A Negative Is a Finding
No meconium staining. No vaginal bleeding. No fever. No foul odor. No decrease in fetal movement reported. Each is written as a finding because each would change the plan: meconium, bleeding or fever would mean a different route.
Assessment
Prelabor rupture of membranes at term, 50 minutes before arrival, group B streptococcus negative, reassuring fetal status, early contractions.
Named, Not Left in the Air
Plan, discussed with the attending at 03:50: admit to labor and delivery. At term with ruptured membranes, induction of labor rather than prolonged expectant management is generally recommended, and A.B. chose induction now rather than waiting (American College of Obstetricians and Gynecologists, 2020). Oxytocin to start at 05:00 if contractions remain irregular; no antibiotic prophylaxis needed with a negative group B streptococcus result. Next clinician: the day resident at 07:00, who will review the oxytocin plan.
References
American College of Obstetricians and Gynecologists. (2020). Prelabor rupture of membranes: ACOG practice bulletin, number 217. Obstetrics & Gynecology, 135(3), e80-e97. https://doi.org/10.1097/AOG.0000000000003700
PA 620 Week 2 instructions, in plain terms
The second week asks for a short, dense obstetric triage note that reads as though someone else will act on it. Write it before the outcome is known. Open with the reason for the contact in the patient's own words, then give your findings. Put times on three things: onset of the complaint, arrival and examination. Record negatives that would have changed the plan as findings, not omissions. State an assessment, then a plan with the next step and the person who takes it named, not left in the air. If your scenario is a walk-in rather than a call, the structure is the same. The fetus is the second patient and needs its own findings. Cite the guidance behind the plan.
How the PA 620 Week 2 example is put together
The note is dated April 9, 2026 and written at 03:55. A.B.'s words describe soaked pajamas at 02:40, clear fluid trickling on standing and mild tightening every ten minutes. Times are listed: onset 02:40, arrival 03:10 and speculum examination 03:30. Findings give normal maternal vital signs, a category I fetal tracing with moderate variability and accelerations, contractions every 8 to 12 minutes, pooling of clear fluid, positive nitrazine, ferning, a cervix about 2 centimeters on visual inspection and a negative group B streptococcus culture at 36 weeks. Negatives list no meconium, bleeding, fever, odor or reduced movement. The assessment names prelabor rupture at term. The plan admits A.B., points to ACOG's practice bulletin for induction, sets oxytocin for 05:00 and names the day resident.
Reading the PA 620 Week 2 grading rubric
Triage notes lose the most when written after the outcome, arranged so every fact points to what happened next. Next comes a note that paraphrases the patient instead of recording the complaint in the patient's words. Graders deduct when the three key times are missing or when the fetus has no findings of its own. Faculty reward negatives recorded as findings, an assessment that names the condition and gestational age and a plan with a named next clinician. Accuracy of findings such as ferning and tracing category is checked. Citation of the guidance behind the plan, in APA form, completes the rubric.
PA 620 Week 2 help from the desk
Triage notes most often fall short by summarizing ("patient with ROM, admitted") without the findings that support the label. Another frequent problem is leaving out the times that decide management. Some notes also omit negatives such as meconium or fever, so a reader cannot tell whether they were checked. If your triage case is different, such as decreased fetal movement, bleeding or headache in late pregnancy, send the complaint and findings; a note prepared for you would quote the patient, time the key events, record findings for both patients, list the negatives that matter and end on a plan with a named next step. If your scenario is a phone call, the examination section would be replaced by advice given.
Get a PA-620 Week 2 example written to your instructions
Send the Week 2 instructions with the call script or vignette your section supplies, and a custom triage entry is written to them and returned inside 24 to 48 hours. The first one is free. If your unit's form has fixed fields, send the field list and the example is built inside it rather than as prose.
More PA 620 papers and MPAS samples
- PA 620 Week 1: Prenatal Record Claim Post
- PA 620 Week 3: Expected Findings Note
- PA 620 Week 4: Labor Course Note
- PA 620 Week 5: Mid-rotation Feedback Memo
- PA 620 Week 6: Postpartum Day Note
- PA 620 Week 7: Two-patient Documentation Brief
- PA 620 Week 8: Case Mix Review
- PA 618 Week 2: Three-Party Encounter Write-Up
- PA 616 Week 2: Pre-Rounding Data Sheet
- PA 614 Week 2: Shift Sign-Out Brief
- PA 648 Week 2: Remediation Contract
PA 620 Week 2 questions, answered
My scenario is a walk-in rather than a call. Does the structure change?
Barely, and one field gets easier, because a walk-in lets the entry record findings as well as answers. What changes is that the instruction is now given in person, and the record still has to carry it in the words used. Note the arrival time as well as the time of writing; the distance between the two is often exactly what a marker is checking.
How much does the second patient need in a triage entry?
Whatever the contact actually produced, recorded on its own line rather than folded into a sentence about her. On a call that may be only what she reports and when she last noticed it. In the unit it may be an instrument reading with a time attached. The defect is an entry that names two people in its heading and then describes one of them.
Do I invent the clinical content or wait for the case?
Work from the case your section gives you and invent nothing the form would treat as measured. Where a vignette leaves a field empty, record it as not obtained rather than filling it, since an entry claiming a reading nobody took is the one defect rewriting cannot repair. Send the vignette and the example is built on exactly what it supplies.
Where can I find a free PA 620 Week 2 sample paper?
A complete PA 620 Week 2 obstetric triage note for prelabor rupture of membranes at 39 weeks, with timed events and named negatives, is on this page.
What three times does the PA 620 Week 2 sample record?
The onset of leaking at 02:40, arrival in triage at 03:10 and the sterile speculum examination at 03:30.