I know that everything anymore in L and D is on the computer but I still like to have a paper sheet more for myself and for giving report. I am looking for some ideas that some of you might use for Labor and Delivery and for sick baby nursery. I work in a level 2 nursery as well as labor and delivery and just thought I would check to see what others used for report sheets.
Sep 15, '07
I don't have any fancy report sheet for LD I usually don't write anything down and sometimes don't for postpartum depending on the number of patients and if I've worked the previous day or 2 to know the patients but when I do write anything down it's a lined paper with a columns I put room number, last name, age, initial of MD (all our docs have different last names so 1 letter does it) date and time of delivery if delivered and type of delivery, breast or bottle feeding, IV or SL and time it can come out, DVT if they need to void, I don't write a diet unless it's not regular, then anything else I need to know like our routing teaching we call moveis so I write that if they need them....so a c/s might look like this for me:
101/Smith/22R/PCS 9-14 2205 FTP/breast/IV-out/DTV/Movies/NM (new mom gift from the hospital if they need it)/astromorph then anything else I might need like if they had a temp or elevated BP I don't write down "normals" we have a cardex for giving report..
At another hospital I worked per diem each patient had a 1/2 sheet of paper which was basically the cardex and report sheet and you could write whatever in pencil on there and anything that stayed the same was in ink ie blood type, rhogam given etc.
Sep 17, '07
If you will PM me with an email address, I'll send you what I have. It's in Excel format and I can't upload it here.
Oct 17, '07
I just uploaded my cheat sheet under the thread "brain sheet for postpartum/antepartum please post" (my sheet is mostly for L&D but I do all of them)
I use parts of the S.T.A.B.L.E. self-assessment/evaluation form (it's really meant for evaluating how you did for a transport) for a sick baby because it has most of the stuff I need to chart/remember. I can jot it down and catch up on the computer later. We are a level 1 and transport most sick babies so I don't know if it would work as well for you, but you could see if someone has the book and look at the form. It's in the STABLE learner manual
Must Read Topics