OB narrative nursing notes

For just an hourly round note, I chart what they are doing and whether or not they have any needs. If they do, I state what it was/how it was met. Some examples:

Patient sitting up in bed talking with visitors. Denies any needs at present.

Perineal cold packs given per pt request.

Pt resting in bed w/ eyes closed. Appears to be sleeping.

For baby I would put something like "Baby remains in mom's room, sleeping in crib." Or "Baby being held by mom/dad/visitor."

Just a quick little note to indicate you laid eyes on the patient.

Our current charting system has boxes you can tick off on an hourly rounds screen plus it has a narrative field so we can chart stuff that may not be addressed by a tick box.

I don't work labor room so I can't speak to what they would be charting hourly.

For just an hourly round note, I chart what they are doing and whether or not they have any needs. If they do, I state what it was/how it was met. Some examples:

Patient sitting up in bed talking with visitors. Denies any needs at present.

Perineal cold packs given per pt request.

Pt resting in bed w/ eyes closed. Appears to be sleeping.

For baby I would put something like "Baby remains in mom's room, sleeping in crib." Or "Baby being held by mom/dad/visitor."

Just a quick little note to indicate you laid eyes on the patient.

Our current charting system has boxes you can tick off on an hourly rounds screen plus it has a narrative field so we can chart stuff that may not be addressed by a tick box.

I don't work labor room so I can't speak to what they would be charting hourly.

Thank you. I have been looking at other nurse's notes too and jotting things down on a cheat sheet when I like how they word something or I notice something I should be charting that I am not.