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PROVIDENCE HOSPITAL 6801 Airport Boulevard, Mobile AL 36608, 251/6331000 NEWBORN ADMISSION NOTES G Term Preterm L A EDC Group B Strep POSITIVE NEGATIVE HISTORY ABNORMALITIES OF THIS & PREVIOUS PREGNANCIES:

How to fill out newborn admission notes

How to fill out newborn admission notes:

1. Begin by gathering all necessary information about the newborn, including their full name, date of birth, weight, and any pertinent medical history or conditions.
2. Record the date and time of admission at the top of the form to ensure accurate documentation.
3. Document the reason for admission, whether it be for routine care, medical evaluation, or other specific concerns.
4. Take note of the newborn's vital signs, including their temperature, heart rate, and respiratory rate. Also, record their blood pressure if applicable.
5. Document the newborn's physical examination findings, including their general appearance, skin color, and any abnormalities or concerns observed.
6. Record any medications given to the newborn, including the name, dosage, and route of administration. Document any allergies or adverse reactions noted.
7. Include information about the newborn's feeding schedule, whether they are breastfed, formula-fed, or receiving other forms of nutrition. Note any difficulties or concerns with feeding.
8. If applicable, document any laboratory or diagnostic test results, such as blood tests or imaging studies.
9. Make sure to document any additional assessments or interventions provided to the newborn, such as monitoring oxygen saturation levels, administering oxygen, or addressing any specific medical needs.

Who needs newborn admission notes:

1. Hospital staff and healthcare providers: Newborn admission notes are essential for nurses, doctors, and other healthcare professionals in the hospital setting to provide comprehensive and accurate care for the newborn.
2. Parents or guardians: Newborn admission notes serve as a record of the baby's medical history and care during their hospital stay, ensuring that parents or guardians have access to important information about their newborn's health.
3. Primary care providers: Admission notes are crucial for primary care providers who will be involved in the baby's ongoing healthcare outside of the hospital setting. These notes provide important context and information for future medical management and follow-up care.

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What is newborn admission notes?

Newborn admission notes are medical records documenting the condition of a newborn upon admission to a healthcare facility.

Who is required to file newborn admission notes?

Healthcare providers such as doctors, nurses, or midwives are required to file newborn admission notes.

How to fill out newborn admission notes?

Newborn admission notes should be filled out by documenting the newborn's vital signs, medical history, and any observations made during the initial examination.

What is the purpose of newborn admission notes?

The purpose of newborn admission notes is to provide a detailed record of the newborn's condition at the time of admission, ensuring proper care and treatment.

What information must be reported on newborn admission notes?

Information such as the newborn's weight, length, Apgar score, any medications administered, and any abnormalities observed should be reported on newborn admission notes.