8/12/2019 Bghmc-nr Sample Charting

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BGHMC-NR SAMPLE CHARTINGDATETIME DATA, ACTION, RESPONSE

_______________Born an alive baby B/G via NSD attended by Dr.______________________

with the presence of NCU nurse / staff.>With minimal vernix caseosa over the body noted.

>With loud cry upon delivery, pinkish in color, active flexion of

extremities noted.

>Placed on the left/right side lying on mothersabdomen.

>Immediate wiping of secretion and drying of blood done.

_______________

>Cord clamping and cutting done by Dr.__________________ after

pulsation ceased.

>Name tag verified, complete and placed on the right ankle by NCU

nurse / staff.>Placed on prone position on mothers chest for skin to skin contact .

>Maintained warmth by proving blanket and bonnet.

>Initial vital signs taken as follows CR=__per min, RR=__per min, T=__C.

_______________

>Trans-out to DR-RR with mother per stretcher while maintaining skin

to skin contact.

>Rooting reflex noted, initiated breastfeeding, with good sucking reflex

upon latching on mothers breast.

>Monitored vital signs every 15 minutes and recorded.

>Health teaching instructed to the mother as follows:a) Breastfeed the baby per demand and burp after feeding.

b) Information regarding self-care, infant care, cord care and safety

considerations,

c) Importance of immunization, new born screening and hearing test.

_______________ >Brought to newborn care area cuddled by NCU nurse/ staff.

>Placed under radiant warmer.

>Erythromycin eye ointment applied aseptically on both eyes from inner

to outer canthus.

_______________ >Vitamin K 0.1ml given IM at right vastus lateralis.>Anthropometric measurement taken as follow:

wt=___kgs, L=___cm, HC=___cm, CC=___cm, AC=___cm, Arm C=___cm

>Cleaned both ears and checked patency of anus.

>Vital signs taken as follows: T= ___C, RR=___per min, CR=___per min.

_______________ >Hepatitis B vaccine 0.5ml given IM at left vastus lateralis.

>Clothed and wrapped baby with blanket.

>Roomed in to mother at DR-RR.

_______________ >Brought to OB ward cuddled by motherper wheelchair.

Rheena B. =)

UC-BCF,BSN3-2C

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NEW BORN FROM LSCS

DATETIME DATA, ACTION, RESPONSE

_______________ >Received from OR to newborn care area cuddled by ROD.>Placed under radiant warmer.

>Pinkish in color, with loud cry and active flexion of extremities noted.

>With name tag attached on the right ankle.

>Erythromycin eye ointment applied aseptically on both eyes from inner

to outer canthus.

>Vitamin K 0.1 ml. given IM at rightvastus lateralis.

>Anthropometric measurement taken as follows:

WT.-__kgs, L -__cm, HC-__cm, CC-__cm, AC-__cm, Arm C-___cm

>Cleaned both ears and checked patency of anus.

>Vital signs taken as follows: T-___C, RR-___per min, CR-___per min.

>Hepa B vaccine 0.5ml given IM at leftvastus lateralis by NCU nurse /

staff.

>Clothed and wrapped baby with blanket.

>Monitored vital signs and recorded.

>Bought back to mother at OR-RR cuddled by NCU nurse / staff.

Rheena B. =)

UC-BCF,BSN3-2C