Pediatric Residency Program: JAX
NURSERYFirst set up your list…After log in choose Department: JX V NeonatologySystem List > Units JX > 3N obstetrics NURTabs to have on your patient list: Patient NameAgeMother InformationMRNNew Rslt FlagNew RsltPend NotesWeightBlood TypeAdmission Date/TimeWrite Hand Off:Pt. Info:Under Dispo – D/C, Note, Admit with dateMaternal Notes:PNC: go to Summary > Maternal Data > Link to Mother’s Chart > Summary > Prenatal Care< 3 – consult case management for inadequate PNCMaternal Labs:Most found under Summary > Maternal Data; or go to mom’s chartGBS: document if treated and if adequate; go to mom’s chart MARCheck the protocolDelivery Info:If ped’s was called, document why? Meconium, breech, shoulder dystocia, etc.Pt Notes:AGA/SGA/LGA – use growth chartEarliest US: mom’s chart > prenatal care notes or mom’s H&PPhysical Exam: only unique findingsCord pH & BE: find in results reviewBlood type: if not done – N/A include Coomb’s testWt. changeTo Do:Add all the things baby will need – bili, voiding, stool, case management, etc.Abbreviations:AG: anticipatory guidanceCSE: car seat evalDBM: donor breast milkFU: follow upHGP: hypoglycemic protocolLN: linea nigraOAE: optoacoustic examORS: overriding suturesPNC: prenatal carePNV: prenatal vitaminsRR: red reflexS: stoolSDWBV: sacral dimple with base visualizedSMS: sacral Mongolian spotSW: social workUDOA: urine drugs of abuseUH: umbilical herniaV: voidedNight ShiftGet sign outPre-scrubStart Discharge summary notes and pend themCheck the board for any upcoming babiesHead over to 3 North and start examining babies around 9 pm, take the ophthalmoscope and tape measure with you. Examine in patient rooms, nurses station or procedure roomAfter midnight when you are done examining babies, finish your notesBefore signing notes – make sure to change the date to after midnight & refresh the note to have the latest birth weight.If by 5 AM patients are missing results - bili, SpO2s, weights - call the nurses.Discharge summary Note:New note Type: Discharge SummaryDate of Service: make sure to change date for after midnightCheck off Cosign Required – select the day time attending (it’s on the calendar)Note template to use .nbndischargesummaryjxGo thru using F2 and making sure all information is accurate and filled in. The note will not always auto populate information.Prenatal care, pregnancy complications, etc. look at the delivery note under progress notes tab.Admission physical exam: look at the H&P note. Make sure to change the red reflex if it was deferred.Nutrition is on the sign out sheetPhysical exam findings: make sure you bold any findings not in the templateAnticipatory Guidance: remove whatever doesn’t pertain to patientProblem list: there should at least be 2 – delivery method and term age of babyHospital Course: you will have to go thru all of the progress notes and include everything that happened:Hypoglycemia protocolSGA/LGA/preterm/infant of DMGBS exposure/treatment/ROMResuscitationSocial work consultationEtc.F/U pediatrician should be in sign out sheetBaby’s 24 hour SpO2 should auto populate, if not Flowsheets Vital Signs Simple. Make sure to document which extremities too.Baby’s 40 hour bili on results reviewStudies pendingSpecial Follow Up needed“I need the neonatal resus team/peds to room…for a …. delivery. And if they say shoulder dystocia you better run.”745490083185What to bring to the delivery?Pen, paper, stethoscopeOphthalmoscope if LD room00What to bring to the delivery?Pen, paper, stethoscopeOphthalmoscope if LD roomCatch the baby and assess immediately for breathing, crying, color, tone and heart rate. Depending on the scenario and who is there you’ll either do skin to skin or take baby over to the panda warmer. Assign the APGARs. If resus was needed, make a mental/written note on what was done and for how long.If possible, do your physical exam at birth and jot it down. Before you walk out ask mom about breastfeeding/bottle.Get the RED REFLEX!! Their eyes open a lot easier at birth, dim the light on the panda, they usually open their eyes. There’s an ophthalmoscope next to the panda warmers in the OR. If mom says bottle, EDUCATE on benefits of breastfeeding and risks of formula. Time for some notes…Every new baby has to get:Admitted & OrdersDelivery note (only if we were called)Problem listH&PADT Navigator > Med Rec-Sign &… Service: NeonatologyAdmitting Diagnosis: term/preterm infant Level of Care: Med SurgEstimated Length of Stay: 2 midnights or longerPost Discharge Plan: Discharge to HomeAdmitting Provider & Update Attending to: attending thereDesired Bed Placement: JX 3N OBSTETRICS NURPed Newborn Nursery Admission Orders > select all your orders > click next until > Summary > sign & holdVital Signs: GBS + mom change vital signs to every 6 hoursPulse oximetry change *** to 24 hoursPatient acuityLevel I for all term babiesLevel II for babies on hypoglycemia protocol, phototherapy, patients requiring antibiotics, HIV, any infant requiring more than routine careNutrition:PO Formula Feeding: Type of formula – similac or neosureLaboratory:Mom’s blood type O and/or Rh neg check off Cord blood evalPOCT bili: calculate 40 hour bili, fill in date & time; click yesUrine Drugs of Abuse: don’t check it off unless mom has signed the consentConsults:Case Management: specify whyUF ID: make sure to call if before 5 PM, after 5 PM tell day team to call in sign outNotes > New noteType: Progress NoteCheck off Cosign Required and choose attending on site.nbndeliverynoteUnder Additional Comments: explain the events at birth, why you assigned the apgars, the details of resus, etc. Review the delivery information, sometimes it doesn’t completely autopopulate, or the delivery nurse may put the incorrect ROM time. Term birth of infant/newborn...Problems will be written multiple ways but will all have the same ICD codeMethod of delivery: vaginal or c-sectionAdd as many problems as you can…some examplesHydroceleMongolian spotLanugoSGA/LGAMaternal GBS exposureTobacco useInadequate prenatal careSearch all problems and add them on Notes > New noteType: H&PCheck off Cosign Required and choose attending on site.nbnhistoryandphysicaljxF2 through the noteAdmission Exam: make sure to bold findingsEx:Head: open fontanelles, overriding sutures, caputSkin: no edema, rash, Mongolian spot, miliaPlan:Include blood type work up, SGA/LGA/infant of diabetic mother/preterm work up, GBS work up, etc. ................
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