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Discussion

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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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.

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.

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.

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

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