BGH CHARTING NURSERY

_____Born an alive baby girl or boy via normal spontaneous delivery attended by Dr. __________________
With strong or weak cry upon delivery, pinkish or acrocyanotic in color.
With abundant or minimal vernix casseosa.
Placed at right side lying position on mothers abdomen.
Immediate thorough wiping and drying of secretion and blood stain done, placed bonnet on babys head.
Maintained warmth by covering with pre-warmed blanket.
_____Cord clamping and cutting done after cord pulsation ceased.
Name tag verified and completed and placed on right ankle by _____________________
Placed prone position on mothers chest for skin to skin contact.
Trans-out to PR-RR with mother by maintaining skin to skin contact.
Rooting reflex noted, assisted mother and initiated breastfeeding, baby with good or poor sucking reflex and breastfeeding
sustained.
Health teaching were given to mothers as follows.
Breastfeed baby per demand and to burp after every feeding.
Keep cord stump clean and dry always.
Never leave the baby unattended.
Emphasized importance of newborn screening.
Advised to perform hand hygiene and hand washing before and after handling the baby.
Keep diaper area clean and dry always.
Avoid using oil, ointment, powder and lotion on babys skin.
Avoid putting binder on cord stump.
Report to NICU staff immediately any untoward observation such as cyanosis, poor suck, fast breathing, and irritability.
Mother acknowledged above health teachings.
__________Brought to newborn care area, placed under radiant warmer.
Routine newborn care rendered aseptically.
________Erythromycin ointment applied on both eye.
________ Vitamin K 0.1 ml injected IM at right vastuslateralis.
________Hepatitis B 0.5 ml injected IM at left vastuslateralis.
Checked patency of anus, with patent anus.
Anthropometric measurements as follows
Weight __________ HC___________Abd C ___________
Length __________ CC ___________ Arm C ___________
Clothed and wrap with blanket.
Vital signs taken as follows.
TT_________ RR __________ CR __________
Brought back to mother at RR.
__________Trans-out with mother accompanied by IW on duty.

SLU BSN II
 DR SAMPLE CHARTING
________Received for LR/ER, ambulatory or per wheelchair or per stretcher with an ongoing IVF of __________+__________U
ocyticin x________gtts/min at _______cc level, infusing on right or left hand; accompanied by ____________________________.
Assisted and positioned comfortably in lithotomy.
Oxygen inhalation administered at 2-3LPM per nasal cannula.
Right medio lateral episiotomy or perineal support done by Dr./Intern/Clerk___________________________________.
________Delivered an alive baby girl or boy via normal spontaneous vaginal delivery by Dr./Intern/Clerk ______________________.
Oxytocin 10 u given IM right or left deltoid.
________Cord clamping and cutting done by Dr./Intern/Clerk____________________, after cessation of cord pulsation.
________Placenta out by Shultz or Duncan presentation by Dr./Intern/Clerk_____________________________________.
BP taken and recorded as _________mmHG
Methylergometrine 1 amp given IM on right or left deltoid (as ordered only).
Evacuation of blood clots and placental fragments done by Dr./Intern/Clerk ______________________________.
Episiorrhapy/Repair of perineal laceration done by Dr./Intern/Clerk ___________________________ used ________piece/s
of vicryl rapide.
Perineal care and betadine swab done
Placed adult diaper and secured.
________Brought to RR per stretcher accompanied by _____________________ with ongoing IVF of _______+______u oxytocin
x_____gtts/min at _____cc level infusing well on right or left hand.
With minimal lochial discharge.
With firm and contracted uterus.
Monitored for possible profuse bleeding.
Advised to massage uterus as needed.
Encouraged to breastfeed per demand and burp baby then after.
Instructed to increase fluid intake and to eat food rich in vitamin-C, Iron and Protein.
Emphasized importance of drug compliance and daily perineal care.
Advised to report any untoward observation.
________Trans-out to ward per wheelchair with ongoing IVF of _______+______u oxytocin x_____gtts/min at _____cc level
infusing well on right or left hand, cuddling baby girl or boy; accompanied by______________________________.

SLU BSN II
 D and C Notes

________Received for LR/ER, ambulatory or per wheelchair or per stretcher or ambulatory, accompanied by ________________
with an ongoing IVF of __________+__________U ocyticin x________hrs at _______cc level, infusing on right or left hand.
Assisted and positioned comfortably in lithotomy.
Oxygen inhalation administered at 2-3LPM per nasal cannula.
Skin prep done by Dr./Intern/Clerk ______________________________.
Draped aseptically.
BP taken and recorded as _____mmHG.
________NalbuphinHel 10mg given IV by _________________________.
________Midazolam 5mg given IV by______________________.
Operation started by Dr./Intern/Clerk ______________________________ whereby speculum is inserted at the vagina.
Evacuation of blood clots/placental fragments done by Dr./Intern/Clerk ______________________________.
Specimen fished out.
________Operation ended.
Betadine swabbing and perineal care done.
Placed and secured adult diaper.
________Brought to RR per stretcher accompanied by ___________________ with an ongoing IVF of __________+__________U
ocyticin x________hrs at _______cc level.
With minimal lochial discharge.
Monitored for possible profuse bleeding.
Emphasized importance of drug compliance and daily perineal care.
________ Trans-out to ward per wheelchair with ongoing IVF of _______+______u oxytocin x_____gtts/min at _____cc level
infusing well on right or left hand, cuddling baby girl or boy; accompanied by______________________________.

SLU BSN II