LEGAL NOTICE TO THE FOLLOWING ALLNURSES SUBSCRIBERS: Pixie.RN, JustBeachyNurse, monkeyhq, duskyjewel, and LadyFree28. An Order has been issued by the United States District Court for the District of Minnesota that affects you in the case EAST COAST TEST PREP LLC v. ALLNURSES.COM, INC. Click here for more information
We have a specific report sheet that everyone in the unit must use. That way, no information about the baby gets lost or forgotten. We were having trouble with some information not getting passed on to the next shift and things getting missed. We also have a kardex that stays with the baby though it's whole stay that documents any kind of procedure or central lines that he/she has had during their stay. It makes it alot easier to remember that kind of information when a kid has been with us for a long period of time.
We also use a bedside Kardex. It is updated daily with all pertinent info begining with maternal Hx and birth info, feeds, neuro, cardiac, meds, labs, any transfusions, etc, etc.
A basic report for me would go something like this: (just an example)
Baby boy XXX
was a 29 5/7 wkr now 33 4/7 first baby, prev. NCPAP now on RA. Occ. A's and B's. Feeds are 160/kg = 35 cc q 3 min. nipple/gavage (has nippled all but one in 24 hrs) Gets ferinsol at XX:XX, etc. Has a CBC, etc. in AM. Head is neg, prev. pda tx with indocin now neg. Parents will be in at XX feed and are independent with care.
That is all of the top of my head (made it up) but it covers most generic things for a grower/feeder with no problems.
We have a bedside Kardex that gets updated with all new orders. We also have a cribside sheet that we fill in off of the Kardex. We have a list of things we have to do for handoff. We have to look at IVs, check HAL and lipids, go over MAR, and vent settings if baby is vented. We go over labs, XRays, and procedures occuring in the next 24 hours. We go over feeds, any social issues, and any discharge needs if baby is getting close to going home. The cribside sheet really helps a lot, it has a box for everything so that if you follow it you know you have your bases covered.
Our kardexes are set up by systems...there is a column for each such as Resp. CV FEN Neuro ID Other. Pretty much each day something is put down under which ever system it belongs, such as under Resp we would put Mulitple desats, inc vent settings, 3rd dose survanta Under CV Echo done...large PDA Neuro HUS done FEN on 100ml/kg/day, mom pumping, NPO ID SWU , and so on.
We use our flowsheet pretty much for drips, IV's feeds. We go thru all fluids and they are double checked, we trace back all lines from pumps to baby, including enteral feeds. We double check 24 hours of orders and sign them off in the chart check and go thru the MAR.
We don't have a specific report sheet that everyone MUST use. We have a generic sheet that people can fill in however they want. People organize things differently, so you have to do whatever works for you.
We have a kardex in the bedside chart that includes everything by system, just like a few others have mentioned. Can't really miss anything in report, because we update the kardex each shift. We also do 12 hour chart checks at the beginning and end of each shift. Our flowsheets, I&Os, IVs, etc are all computer charted.
Make out a sheet that works for you. I have my sheets with hourly blocks and I fill in everything I need to get done at certain times (assessments, feeds, meds, labs, etc.). During report I write down system by system the important things, but I can refer to the bedside kardex for anything else I need to look up. Just have to find something that'll work for you, and it might take some trial and error, practicing with different methods until you find something that really works for you.