Neonatal Notes Documentation Audit 2006

Neonatal Notes Documentation Audit 2006 Dr M Saibaba,SHO Dr Jayalal, Consultant Paediatrician Facilitated by: The Clinical Audit & Effectiveness Department

Introduction • Objectives: • To ensure documentation of neonatal notes is being completed correctly. • To improve record keeping where appropriate. • Rationale: • To improve the quality of documentation of notes.

Criterion 1 (a – d) • The following details of the mother will be completed on the admission sheet: • Mothers blood group • Rubella titres / status • Past medical history • Previous pregnancies

Criterion 1 (e – g) • The following details of the mother will be completed on the admission sheet: • Scan data abnormalities in this pregnancy • Steroid administration • Smoking history

Criterion 2 • The following details of labour will be completed on the admission sheet: • Onset • Gestation • Membranes ruptured for (x) hours • Foetal distress • Intrapartum antibiotics

Criterion 3 • The following details regarding the condition of the baby will be completed: • APGAR score at 1 and 5 minutes • Resuscitation required • Paediatrician present or not

Criterion 4 (a – d) • The following details will be completed on admission: • Birth weight • Temperature • BMI Stix • Head circumference

Criterion 4 (e – g) • The following details will be completed on admission: • Length • Growth chart • Vitamin K given

Criterion 5 • The following details will be completed on examination: • Age of baby in hours • Complete assessment

Criterion 6 (a – d) • The following details will be completed on discharge: • Date • Age • Weight • Length

Criterion 6 (e – g) • The following details will be completed on discharge: • Head circumference • Discharge checks • Feeding

Criterion 7 • The following follow-up information will be recorded: • Date and place • Guthrie test • Audiology screening

Criterion 8 • Every sheet will have baby’s details on the top of the page.

Criterion 9 • Admission entries in the notes will be: • Dated • Timed • Signed with designation and bleep number

Criterion 10 • Problem sheet will be completed.

Conclusions • Good performance: Baby details on every sheet Doctors details, date, time • Poor performance: Membrane rupture APGARS Admission observations Vitamin K Complete assessment on the 1st day Follow up plan Problem sheet

Recommendations • Improvement in the admission entry details • Reaudit in 3 months time

Neonatal Notes Documentation Audit 2006