CENTER FOR CLINICAL LEARNING
Student Name: _____________________________________ Date: ____________
Newborn Assessment SBAR Report
S
Highlight appropriate responses where applicable
Male/Female:
Room #
Date and Time of Delivery:
Physician:
Delivery complications:
Weight:
Length:
Apgar:_______ @ 1 min
Apgar:_______ @5 min
Breast/Bottle
Blood type:
B
Mom GBS +/- treated with antibiotics? Y/N # of doses:
Pregnancy complications:
Gestational Age:
Vaginal/C-Section
Indication for C/S:
Moms past Medical hx:
Labor/Delivery complications:
Maternal use during pregnancy:
Smoker Y/N
Alcohol Y/N
Drugs Y/N If yes, list which ones
A
Times
Temp
Heart
rate
Respirations
NIPS and interventions provided and
revaluation of pain
Today’s wt:
Amount loss or gained since birth:
Feedings during this shift:
Breast: Time:
R/L breast How long:
Latching difficulties Y/N
Time:
R/L breast How long:
Latching difficulties Y/N
Time:
R/L breast How long:
Latching difficulties Y/N
Time:
R/L breast How long:
Latching difficulties Y/N
List any breastfeeding concerns:
Bottle: Time:
Amount:
Time:
Amount:
Time:
Amount:
Time:
Amount:
List any bottle feeding concerns:
mL
mL
mL
mL
Skin turgor: immediate/tenting Mucus membranes: Moist/dry Cap refill: Brisk/slow
Skin color: Acrocyanosis/normal for ethnicity/pale/ruddy/jaundice/bruising
Caput: Y/N Cephalohematoma Y/N Molding Y/N Overriding sutures Y/N
Anterior Fontanel: flat/sunken/bulging Posterior Fontanel: flat/sunken/bulging
Blood glucose: Time:
results:
Time:
results:
Interventions:
A
# of voids since birth:
Voids during this shift:
Time:
Time:
Time:
Time:
# of stools since birth:
Stools during this shift:
Time:
Time:
Time:
Time:
Stools: Meconium/transitional
Bowel sounds:
active/hypo/hyper/absent
Cord clamp: Intact/removed
Circumcision complete: Y/N
Circ complications:Y/N If yes list
complication
Cry:
Strong/Weak/Shrill/High Pitched
Lungs: Clear/crackles/wheezes
R
Reflexes:
Moro Y/N
Grasp Y/N
Babinski Y/N
Rooting Y/N
Neonatal Abstinence Syndrome
Y/N If yes: times and scores:
Pending labs:
Hearing screening complete: Y/N Right ear: Pass/Refer Left ear: Pass/Refer
Hep B given: Y/N
CHD complete Y/N Results: Right hand__________ Foot_______
Newborn screening complete: Y/N
TcB complete Y/N results:________________
Bilirubin lab levels needed Y/N results:______________
Teaching needs:
Notes:
Newborn Diagnostic Evaluation (Needs to be completed once)
Textbook Source (Include page numbers)
Name of test or
procedure
Bilirubin
Congenital Heart
Disease
Hearing Screening
Normal Range
Results
Purpose of Test –
Why was it done
for your patient?
Two nursing
interventions
related to results