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  #1  
Old Jan 30, 2007, 11:52 AM
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Join Date: Jan 2007
nursing documentation

Hello everyone! I am a supervisor/staff educator in northcentral west virginia and our hospital does about 950 deliveries a year. We are revising some of our policies and wanted to see what some other facilities are doing. Newborn documentation, what does your policy say on how often a well newborn has to be assessed and documented on? I can't really find an guidelines and our old policies have a lot of things that say "q shift", but that was when we were doing eight hour shifts, and of course most of our nurses are doing twelve. I would appreciate any input!!

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  #2  
Old Jan 30, 2007, 01:34 PM
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nurse hobbit (Female)
I like Monkies!
Join Date: Jan 2006
Re: nursing documentation

At the facility where I work, all newborns and peds have to have documentation every 2 hours! Full assessments once a shift, but IV checks, o2 sats q 2 and vitials q 4 no matter what. Hope this helps.

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  #3  
Old Jan 30, 2007, 10:53 PM
Registered User
Join Date: Apr 2004
Re: nursing documentation

Where I work we document on babies every 30 minutes for the first two hours following birth. As long as all vitals are stable we document at start of shift then q8hours. We also have many protocols in place regarding low temp babies, low blood sugar babies, s/s of sepsis and so on and so on. If any baby falls into those categories we follow the particular protocol related to that baby for assessments and reassessements and charting.

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  #4  
Old Jan 31, 2007, 12:40 PM
Registered User
Join Date: Feb 2005
Re: nursing documentation

There is a standard of care the says you must visually check newborns every two hours. I have am off for a few days, and I can't remember where that standard lives. We do q15 min VS for 1 hour, then q 4 hours x 24 hours. After that q shift with q 4 hour temps.

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  #5  
Old Jan 31, 2007, 02:34 PM
Registered User
Join Date: Jan 2007
Re: nursing documentation

Our policy at the facility where I work is the same policy that nurse hobbit stated at her facility.

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