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NURSES NOTES
NAME OF PATIENT: AGE: DIAGNOSIS:
DATE/TIME
FOCUS
DATA/ACTION/RESPONSE
Received from to an alive baby out @ thru
Respiratory Status
Attended by Dr.
D > Appearance:
Cry and Reflexes:
Anus:
Congenital Malformalities:
Others:
A> Immediate and thorough drying, secured name tag @ Right ankle
Latched-on and early skin to skin contact between the mother
& Newborn done
Properly timed cord clamping and cutting done aseptically
Non- separation of newborn from the mother to initiate early
Breastfeeding and kangaroo care done
Anthropometric measurements done
Routine Newborn Care done
Crede’s Prophylaxis O.U. given
Vitamin K 0.1ml IM given
Hepa B Vaccine 0.5ml IM given
for NBS, BCG after 24 hrs.
Kept warm and dry, placed under droplight
For CBC, PC, BT-req.
For Hgt
CXR-APL
Inserted Heplock Aseptically
Suctioned Secretions PRN
O2 Inhalation @ ________________per nasal cannula
Bagmask/Intubation:____________________________
Venoclysis:________________________________
ROD Notified, Explained to relatives abt. the baby’s condition
R> Able to breathe effectively, pinkish in appearance
Roomed-In with the mother
Admit to NICU for further management and evaluation,
Accompanied by Hold-over NOD & Relatives
________________________,RN
FM-NUR-NNHOA

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NURSES NOTES NAME OF PATIENT: DATE/TIME AGE: FOCUS Respiratory Status DIAGNOSIS: DATA/ACTION/RESPONSE to an alive baby out @ thru Received from Attended by Dr. D > Appearance: ➢ Cry and Reflexes: ➢ Anus: ➢ Congenital Malformalities: ➢ Others: A> Immediate and thorough drying, secured name tag @ Right ankle ➢ Latched-on and early skin to skin contact between the mother & Newborn done ➢ Properly timed cord clamping and cutting done aseptically ➢ Non- separation of newborn from the mother to initiate early Breastfeeding and kangaroo care done ➢ Anthropometric measurements done ➢ Routine Newborn Care done ➢ Crede’s Prophylaxis O.U. given ➢ Vitamin K 0.1ml IM given ➢ Hepa B Vaccine 0.5ml IM given ➢ for NBS, BCG after 24 hrs. ➢ Kept warm and dry, placed under droplight ➢ For CBC, PC, BT-req. ➢ For Hgt ➢ CXR-APL ➢ Inserted Heplock Aseptically ➢ Suctioned Secretions PRN ➢ O2 Inhalation @ ________________per nasal cannula ➢ Bagmask/Intubation:____________________________ ➢ Venoclysis:________________________________ ➢ ROD Notified, Explained to relatives abt. the baby’s condition R> Able to breathe effectively, pinkish in appearance ➢ Roomed-In with the mother ➢ Admit to NICU for further management and evaluation, Accompanied by Hold-over NOD & Relatives ________________________,RN FM-NUR-NNHOA Name: Description: ...
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