Documenting Baby’s Birth
Mom’s Chart-Delivery/Primary RN
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RN calls Unit Clerk to notify Admitting of birth, need for registration
In IView-Primary RN charts for BabyCharting on Mom’s chart
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Newborn Delivery Data band o Baby or Fetus A dynamic group should have already been added
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Chart Apgars
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Newborn interventions at birth o Resuscitation at birth is documented on paper-current process
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Primary RN-Go to NB Newborn Systems Assessment Section to chart Initial Newborn Exam
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.
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Enter appropriate IPOC Newborn Care
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Measurements
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Footprints
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Bath
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ID and HUGS tag
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Security photo
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Allergies
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Administer meds as usual using PDA
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For on-going care follow unit standards for document.
Newborn related Tasks-check mom/baby or baby tracking shell
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4 limb blood pressure if ordered
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Hearing screening task-no earlier than 12 hr. after birth
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Newborn screening task-at or after 24 th hour
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HUGS tag check task-every shift
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Remove cord clamp task-24 hours after birth unless indicated otherwise by provider
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Newborn weight task- 24, 48, 72, and 96 hours (birth weight not being tasked)
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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.
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Meconium Screen Indicator task @24 hrs-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.
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From NB Newborn Systems Assessment Band o V.S. o Measurements for weights in kg o Assessment Summary
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Click blue text for reference text
 WDL indicates within defined limits
 If variance is noted, click system on navigator to document variance.
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.
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