Updated: Published
Members are discussing different report sheet templates and methods for organizing patient information in a mother/baby/antepartum unit. They are sharing tips on how to structure the report sheet, what information to include, and some members are requesting copies of specific report forms to help streamline their workflow.
Our report sheet looks like a piece of notebook paper turned sideways & the lines run sideways too. Lines are a lot wider than notebk paper too. It's divided into columns. #1) Pt name 2) Dx SVD, c/s, AP, the occasional TAH 3)Doc 4) Diet 5)Activity 6) I/O (usu only if has IVF or is DTV) 7) VS/assessment frequency 8)misc. I put my baby info under #8, although I don't think it's exactly miscellaneous.
I usually divide my paper into sections by highlighting q4 lines. Gives me enough rm to write all my pt info -- blood type, rubella, if any lacs, G/P, allergies, things like that -- under the pt's name. the other stuff is kind of self explanatory until #8. That's where I write baby info -- something like breastfeeding boy (using abbrevs of course) for XYZ Peds, birth weight, & gestational age.
If Mom is on any meds, I write those in the middle in red ink so I don't miss them, & I write the times (remember there's usu lots of space with 4 lines and only 1 taken up with MD name, diet, activity, etc.
If Baby needs a bili (or anything else), that goes under the baby info.
I take the bottom 2 lines under baby info to write what the couplet needs for d/c, and what is already done. Example:
needs:birthcert, corificeat, PKU, finish teaching
done: hearing, HepB, MMR, Depo, cordclamp
Hope this helps. If it sounds confusing, I'll try to find a copy to scan & PM you.
Also, where in MI are you? (feel free to PM me with that answer) I have g-parents in the Adrian area.
Our report sheet looks like a piece of notebook paper turned sideways & the lines run sideways too. Lines are a lot wider than notebk paper too. It's divided into columns. #1) Pt name 2) Dx SVD, c/s, AP, the occasional TAH 3)Doc 4) Diet 5)Activity 6) I/O (usu only if has IVF or is DTV) 7) VS/assessment frequency 8)misc. I put my baby info under #8, although I don't think it's exactly miscellaneous.I usually divide my paper into sections by highlighting q4 lines. Gives me enough rm to write all my pt info -- blood type, rubella, if any lacs, G/P, allergies, things like that -- under the pt's name. the other stuff is kind of self explanatory until #8. That's where I write baby info -- something like breastfeeding boy (using abbrevs of course) for XYZ Peds, birth weight, & gestational age.
If Mom is on any meds, I write those in the middle in red ink so I don't miss them, & I write the times (remember there's usu lots of space with 4 lines and only 1 taken up with MD name, diet, activity, etc.
If Baby needs a bili (or anything else), that goes under the baby info.
I take the bottom 2 lines under baby info to write what the couplet needs for d/c, and what is already done. Example:
needs:birthcert, corificeat, PKU, finish teaching
done: hearing, HepB, MMR, Depo, cordclamp
Hope this helps. If it sounds confusing, I'll try to find a copy to scan & PM you.
Also, where in MI are you? (feel free to PM me with that answer) I have g-parents in the Adrian area.
I know it's been awhile since you posted this message but you sound really organized and I would love to have a copy of this report form. I normally work NICU and sometimes float to FCC and REALLY need a good way to enter all I have to do. If you can send me a copy, I would greatly appreciate it!
Here is my mother/baby report/assessment sheet. It is all i need when i need to call a doctor about a patient.
deacn
5 Posts
Anyone have a great report sheet for organizing the day? I need a jump-start for complete burn-out. I can't seem to keep up the pace anymore. I work on a mother/baby/antepartum unit and have 4-5 adults plus their babies for a 12 hour shift. Alot of discharges and transfers from L&D, and as you all know, tons of charting, and teaching. We have no ancillary help, except lousy unit coordinators, so we even have some of their work to do.