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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