Bghmc-nr Sample Charting
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Transcript of Bghmc-nr Sample Charting
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8/12/2019 Bghmc-nr Sample Charting
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BGHMC-NR SAMPLE CHARTINGDATETIME DATA, ACTION, RESPONSE
_______________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 mothersabdomen.
>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.
Rheena B. =)
UC-BCF,BSN3-2C
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8/12/2019 Bghmc-nr Sample Charting
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NEW BORN FROM LSCS
DATETIME DATA, ACTION, RESPONSE
_______________ >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.
Rheena B. =)
UC-BCF,BSN3-2C