Well baby visits

[nurseinmo]

We have just gone through some software changes and we are a very small agency and none of us are really "baby nurses" if ya know what I mean.. anyway, my question is, what are "must chart" things for a well baby visit? I am going to have to rebuild our assessment and need some expert input! :)

thanks!

[annaedRN, RN]

We dont have any assessments on our software - we use paper forms. But the major points - VS (not necessarily BP unless problems exist), weights, fontanels, reflexes, feedings ( type, amt, frequency, tolerance), regurgitation, stools (thorough assessment), urination(how much/how often), perineum/rash/circumcision, umbilicus, sleep/wake pattern, bonding, safety (crib, environment, pets, smoking, car seat). Teach proper feeding, sleep position, coping/emotional status (prevention of shaken baby syndrome), assisting agencies (WIC, early intervention, medical assistance...)

If doing assessment on mom - BUBBLE-HE - breasts, uterus, bowel, bladder, lochia, episiotomy/incision, homans sign, emotions.

This of course is just a starting point - hope it helps.

[nurseinmo]

THANK YOU!! That does help quite a bit actually. I wish they would let us use the paper forms for ours, esp since we don't do OASIS on infants and we usually don't see the moms as patients. The last time the people from this software company was here they sat with us and helped us "build" a peds assessment but it still isn't right, things are missing and some of it is totally off the mark as far as what we are looking for so I'm hoping that now that I'm starting to figure the system out I can go back and revamp it to make it what we really need it to be! :)