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BGHMC-NR SAMPLE CHARTING DATE & TIME _______________ DATA, ACTION, RESPONSE

Rheena B. =)

UC-BCF,BSN3-2C

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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 mothers abdomen. >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.

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NEW BORN FROM LSCS DATE & TIME _______________ DATA, ACTION, RESPONSE

Rheena B. =)

UC-BCF,BSN3-2C

>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.