Documentation

Consent

Blood transfusion

Prior to blood transfusion, a discussion between the neonatalogist and the parents must occur, followed by parental consenting. the discussion should be documented in the neonatologist’s admission H&P or daily progress note.

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Donor breast milk

Refer to Donor Breast Milk for details.

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Circumcision

Refer to Circumcision for details.

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Daily Progress Note Component Reminder

PICC

When a PICC is in place and is working properly, document the following in the daily progress note:

Central line/dates: peripherally inserted central catheter: date placed: MM/DD/YYYY. PICC central line assessed today, is functioning well with no signs of inflammation. Plan: Will continue the use of the catheter fo rlong-term paretneral nutrition and/or blood draw.

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Skin-to-skin

Parents are expected to do at least 1 hr of kangaroo care (skin-to-skin, STS) with the infant each day of their visit.

A nursing communication order should be placed on admission to encourage skin-to-skin, One an order is placed, it should be documented in the progress note as follows:

Skin-to-skin order placed.

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Discharge Summary Component Reminder

TREATMENT/CARE GIVEN/COURSE OF HOSPITAL STAY

Examples:

• Status post enteral and parenteral nutrition
• Status post respiratory support for hyperMg and TTN
• CARDIORESPIRATORY EVENTS requiring Caffeine
• Status post antimicrobial therapy for rule out sepsis (blood c/s negative to date )
• CRANIAL ULTRASOUND negative
• Status post phototherapy for non-hemolytic jaundice

Brief Synopsis

Example:

30.3 wks AGA male infant admitted to NICU on 9/18 via transfer from FKP for continuation of care for prematurity (high census) and received the following care:

• NG feeding, Status post TPN/IL
• Anemia treated with Epogen and Iron
• Monitoring for cardiorespiratory events
• Status post circumcision
• History of antimicrobial therapy with negative Blood c/s at FKP
• History of respiratory support for TTN at FKP

Post discharge follow up needs: nutrition using discharge diet of SSC 30 KCal/oz x 2 feedings/day, remainder mother’s bmilk 20 KCal/oz or Neosure 22KCal/oz, follow up with HIGH RISK INFANT F/U CLINIC/ INLAND REGIONAL, Dynamic hip US 6 wk - 4 months old, follow up Anemia.

Deferred Cord Clamping

Deferred cord clamping (DCC) can be documented in the mother’s chart by going to the “Delivery Summary” tab before it is signed by an OB physician.

Below are screenshots from Health Connect to locate the DCC section:

Important

For multiple gestation, each infant has his/her own section to fill out.

Checking Oral Care Documentation

• Step 1: Click “Flowsheets” tab

• Step 2: Click “Shift NICU” tab

• Step 3: Open drop-down list “Safety/Identification/Care”

• Step 4: Click on “Care”

• Step 5: In “Hygiene” row, hover your mouse over boxes to see if “Oral Care w/ colostrum” was documented.

  IMPORTANT: It must include the “Oral Care w/ colostrum” for it to count for our metric. If it only says “Oral Care” but does not include “w/ colostrum,” it will not count.

• Step 6: document in progress note

Family and Medical Leave Act (FMLA) Document Preparation

• Step 1: Click on arrow near the wrench for the drop down menu and locate “Activity Rx4”

• Step 2: Once on this page, select the “caregiver” button on the left

• Step 3: Fill out the appropriate dates you would like for FMLA, the requirements of the caregiver, and the diagnosis

• Step 4: Select “Go to Preview, Print, & Sign.” Print if the parent is requesting a copy. Otherwise, ok to just e-sign.

• Step 5: This process is then documented in the patient’s chart, where social work, case managent, etc. can locate the document ad lib: