Download Documenting Baby`s Birth

Documenting Baby’s Birth
Mom’s Chart-Delivery/Primary RN
 RN calls Unit Clerk to notify Admitting of birth, need for registration
In IView-Secondary RN charts for Baby-Charting on Mom’s chart
 Newborn Delivery Data band
o Baby or Fetus A dynamic group should have already been added
 Chart Initial Newborn Assessment and all Newborn Delivery Data, including Apgars and
measurements.
 Newborn interventions at birth
o Resuscitation at birth is documented on paper-current process
In the event of a baby being born outside of the department
use the Customize icon
on the NB Systems Assessment Band in the baby’s chart
to place the Initial Newborn Exam On View by checking
the box.
Document1
Secondary RN-Go to Baby’s Chart
Admission Newborn Services PowerPlan entered by provider. If RN enters, use provider’s name with
POE cosign or POE VORB/TORB for verbal orders.





Enter appropriate IPOC Newborn Care
IView-NB Newborn System Assessment to chart:
o Bath
o ID and HUGS tag
o Security photo
Allergies
Administer meds as usual using PDA
For on-going care follow unit standards for document.
Newborn related Tasks-check mom/baby or baby tracking shell
 Hearing screening task-no earlier than 12 hr. after birth
 Newborn screening task-at or after 24th hour
 HUGS tag check task-every shift
 Remove cord clamp task-24 hours after birth unless indicated otherwise by provider
 Newborn weight task- 24, 48, 72, and 96 hours (birth weight not being tasked)
 Hyperbilirubinemia screening-if bili reading at 24 hours is equal to or greater than 7, order
serum bili. Once RN documents a bili equal to or greater than 7, a rule will fire an order for
the serum bili.

Meconium Screen Indicator task-informs RN to review mom and newborn risk factors to
determine if a meconium drug screen should be collected. The Admission Newborn
PowerPlan order gives the RN permission to send a specimen and enter an order if the
indicators have been met.

From NB Newborn Systems Assessment Band
o V.S.
o Measurements for weights in kg
o Assessment Summary
 Click blue text for reference
text
 WDL indicates within defined
limits
 If variance is noted, click
system on navigator to
document variance.
Document1
Example: Respiratory Variance
Click variance under
assessment summary; go to
associated system on navigator
to document details of
variance.
o Make sure to document the
assessment status, as this field flows
to the Postpartum Tracking Shell to
inform staff of last assessment.
Document1