Research College of Nursing Mother-Baby Care Report (Hand-off) Form

MOM

Patient ______ Room ______ HC Provider ____________ Staff RN _____________ Date of Care _____________ Student ____________

Age _______ Del. Date/Time ______________ SVD or C/S ____(C/S indication) ____________________ Gravida ____ Para ____ AB ____ LC ____

Bld Type/Rh ___________ Rubella (imm/nonimm) Hep Screen(+/-) Group B Strep(+/-) treated? (antibiotics/#doses) ______________/___________
Allergies _______________ History/Complications __________________________________ Lab ordered (postpartum Hgb & Hct) _______/_______

Fundus __________ Lochia __________ Perineum/Incision _________________ (REEDA, tears/lacerations/epis)

Breasts/Nipples _____________

Dressing ___________ Voiding/Foley ________ IV/Lock/Site _________ I&O _____/_____ Activity _____________ Diet ___________ tDap/Rhogam
VS: B/P_____T_____P_____R_____ Breath sounds ________ Bowel/flatus/ BM Last Pain Meds (time)/Score ______/______ Discharge Date ______

VS/Assessments (times?) ___________/___________ Scheduled Meds (times?) _________/________ Reassess Pain? _______/_______
Bath/Bed Change? _______ Fresh Water/Linen? _______ Hourly Rounding? _______ Teaching? _____________________Procedures? __________

BABY

Birth wt ___________ Today's wt ____________ %Loss ________ Blood type/Rh ________ Coombs _______ Apgars ______/_______

VS: T_____P_____R_____ Voids ______ Stools ______ Last feeding _______ Blood glucose (heal sticks) _______ Bili level______ Jaundice_____

VS/Assessments (times?) ______/______ Circ/Consent signed/time? __________ PKU? _____ Hearing Screen (pass/fail)? ____ Birth Cert? _______

Female/Male ________ HC Provider _____________Gestational Age________ Breast/Bottle (formula type) _________________________

Student Schedule
Break ________ Lunch ________ Clinical Conference __________ Report off to staff nurse ______ Report off to Instructor/Charting checked ____________

Include the following (in SBAR format) in your hand-off to Staff RN:
MOM Last VS/Assessments & time______________________ Last Pain Meds/Score ___________/_____ Diet/Activity Change ___________/__________
IV/saline lock/foley/Dced? _________ Teaching sheet/BC completed: ________ Daily care completed (Linen change/Bath) __________ New Orders? _____

BABY Last VS/Assessments & time___________________________ Voids/Stools/Charted? ______ No. of feedings ________ Last feeding ____________
Amount formula/time @ breast ____________ New orders? _______________

Notes/Plan for the Day/Hourly Rounding Schedule:

Research College of Nursing

Maternal History/Assessments

Newborn History/Assessments

Psychosocial: Significant other/family __________________________________

Family type _____________Family Developmental Stage ____________________
Returning to work ______________Childcare _____________________________
Culture/Ethnicity ____________Childbearing Customs ______________________

Labor and Delivery admission labs: Hgb & Hct ____/____ Platelets __________
Compare L & D Hgb & Hct to Postpartum values: % change _______/________

Labor History: ROM (date/time) __________ Fluid Appearance ___________

EBL _______ Analgesia/anesthesia __________________________________
Length of Stage I _________ Stage II __________ Stage III __________
Complications: Fetal decels ________________ variability ______________
Bradycardia/Tachycardia ________Maternal fever _________
Neonatal resuscitation: Blow-by O2 ________ PPV _________
Additional Assessment Data: Heart sounds _______ Breath sounds_______
Apnea ____Color ______ Acrocyanosis ____Capillary refill _____ Molding ___
Caput _____ Cephalohematoma _____ Sutures _____ Fontanelles _________
Bruises ___ Lacerations __ Mongolian spots ___ Milia ___ Erythema toxicum __
Telangiectatic nevi ___ Umb cord ____ Bowels sounds _____ABD ____
Clavicles (crepitus) ___ Activity _______ Posture ______ Reflexes (Moro- suckbabinski-grasp) Cry ___ Consolability ___ _Anomalies ____________________
Gestational age: SGA-AGA-LGA sole creases/ testes/labia/breasts __________
Nutrition/ I & O: (Breast/Formula) Freq _________ Duration/Amt _________
Voidings/24 hours __________Stools/24 hours ____________
Circumcision: Type (Gomco/Plastibell) _____________Circ care ________
Site assessment ____________ Instructions to parents __________________

Prioritized Problems/Diagnoses for Mom

Prioritized Problems/Diagnoses for Newborn

1. ____________________________________________________
2. ____________________________________________________
3. ____________________________________________________

1.___________________________________________________
2.___________________________________________________
3.___________________________________________________

Prioritized Strategies/Interventions for Mom

Prioritized Strategies/Interventions for Newborn

1. ____________________________________________________
2. ____________________________________________________
3. ____________________________________________________

1.___________________________________________________
2.___________________________________________________
3.___________________________________________________

Outcomes of Care: ______________________________________

______________________________________________________
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Outcomes of Care: ____________________________________

____________________________________________________
____________________________________________________

Evaluation/Patient Responses: ______________________________

Evaluation/Patient Responses: ____________________________

______________________________________________________
______________________________________________________

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Previous pregnancy history: Date _____ (Vag or C/S) _____ Sex _____ Wt. ____
__________________________________________________________________
Prenatal care: Trimester started _______________ Total wt. gain _____________
Meds/Herbs taken _______________ Tobacco/alcohol/drugs _________________
Illnesses/complications during pregnancy _________________________________
Prenatal Labs: First Hgb & Hct ____/____ Glucose screen _______
HIV _____ RPR/VDRL ______
Past health history (chronic diseases, depression, abuse, surgeries):___________
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