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Newborn Service

How to gather pre-round data


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Selecting patient in OBTraceVue
Clicking chalkboard
shows all patients
You can toggle
between mom and
baby modes
Room # next
to pt name
Find your patient
and double click to
select
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Moms basic info
After double clicking on
patient, click single patient
trace to show info
Moms age
Date of delivery
Gestational age (#wks/#days)
Mode of delivery
G/P (P is pre-delivery, so this is G6 P3 now 4)
Moms reg#
Moms DOB
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Delivery data
Click the Delivery
icon
Click the
first Delivery
tab
Time of delivery
APGARs
Type of C-section and indication
(planned, unplanned, why?)
Birth weight
(must be entered
into CareWeb
Continuity to get
percentile)
VitK and
erythromycin
ointment given?
Delivery complications?
Epidural/Meds
LROM (Duration) or length
to rupture of membranes)
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Labor data
Click the
Labor tab
GSB+/-
Tx?
ABO
Abs +/-
HBsAg
R
RPR
To see when and what abx they got for GBS, click on Notes icon
Check Meds/IV
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Labor data, moms ultrasound
Look for moms reg # on Careweb to see gonorrhea, chlamydia, and HIV status
Look through Lab data for the appropriate results
For a shortcut, type in chli,gci,ahiv in the
search box and click Lookup
(This will give you the table below. No result
means test was not performed)
For moms ultrasound report, go to Documents (Doc Type ULTRASOUND)
Can scroll through
here and click
ULTRASOUND to
filter results
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Exam tab/Hx
Click on Admission
records
Click on
Examination tab
If depression and domestic screens were
performed, they will show up here
- Green - means screen was negative
- Positive findings will be a red +
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D/C list
Click on this icon
and switch to baby
mode
Click on the Chart icon
Scroll through to see how
much baby has fed and
whether void and mec
have happened
Shows current age and last
checked weight
(% down from birth weight)
Click on Feeding-I/O tab
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D/C list
Weight
Length
Head Circ.
To get percentiles on measurements,
look up babys reg #, click on
Continuity and Add Vitals/Growth
Data (you have to manually add in
data from TraceVue)
Click on Shift Assess tab
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D/C list
Glucose
Transcutaneous
bilirubin
If you get serum bilirubin levels, go to
babys Careweb and look at Labs
Click on Vital Signs tab
SpO
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Click on Lab tab