Newborn Workflow

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Newborn Admissions

  • Examine patient after delivery
  • Complete Admission H&P. Please consider using, and saving as your own, the shared Newborn Admission template for boy and girl by McClure and Hampton or Pelkan’s pre-completed shared newborn note. They are pre-completed for normal newborns so you will need to change the exam for any abnormalities. They contain a good outline of what the admission note should include and you can modify it to your liking. These include maternal prenatal information that is helpful for the baby that needs to be seen in follow up.
  • Complete newborn orders
  • Complete medication reconciliation
  • Place an E&M charge order

Newborn Rounding

Babies must be rounded on daily

  • Complete progress note on the baby daily. If night float delivered the baby, they will round and follow the patient until discharge, if they are still on shift.
  • Check 24 hour pulse ox result and make sure NB hearing screen is completed
  • Check lab tests ordered or done by nursing. All infants will get a fractionated bilirubin done before discharge. Some infants will have glucose monitored for jitteriness, LGA, SGA status etc. Some infants will have a Coombs ordered for ABO incompatibility.
  • Document weight with %loss, vitals, feeding and how the baby is doing
  • Place an E&M charge

Newborn Discharge Process

Complete a Newborn Discharge Summary on all newborns

Dee Dee Paster has a good-shared newborn discharge note that you can use and adapt as your own. It has a place to cut and paste all the mom’s prenatal labs from the mom/baby’s admission note and she has put a line at the bottom for birth weight/discharge weight and % weight loss, and what the bili was. That way it’s easy to find for future reference.

  • Provide patient education such as Newborn Booklet-PEDS 9.8.13 Custom, Late Preterm Newborn PEDS 7.9.13 Custom, Circumcision, Jaundice information etc
  • Be sure the patient will get a 3-5 day of life follow up appt, 2 week and two month follow up appts or other f/u as needed
  • Complete the Medication Reconciliation
  • Place an E&M charge
  • Update Diagnoses and Problem List if indicated

OB & Newborn Main Page