NAME_________________

______________________________________________
__

TIME OF DELIVERY_______________

VOIDING: Y / N

V______C________EPISIOTOMY: Y / N
COMPLICATIONS______________________________
______________________________________________
___

PASSING GAS: Y / N
OUT_____________
DIET ____________

G______ P_______

BABY

ALLERGIES ____________________
BLOOD:

A O B AB

+

PEDIATRICIAN______________________________
___

-

MALE_____ FEMALE_________

NEED RHOGAM: Y / N

WT:_______LBS________OZ________GRAMS

RUBELLA: IMM / NON

APGARS:______1MIN________5MIN

HEP B: POS / NEG

GESTATION:_______WKS________DAYS

HIV: POS / NEG
VS

080
0

IN________________

BREAST / BOTTLE / BOTH

120
0

160
0

FEEDING? Y /
N_________________________________

T

LACTATION CONSULT: Y / N

PEE: Y / N

POOP: Y / N

BP

HEP B: Y / N

RR

HEARING TEST: Y/ N

O2

BLOOD:

PAIN

A O B AB + -

COOMBS: NEG / POS
B

U

B

B

L

E

H

E

PKU: Y / N

08
00

VS

12
00

16
00
NOTES_______________________________________
______________________________________________
__
MEDS:_______________________________________
______________________________________________

0800

1200

1600

T

RR

LABS
______________________________________________
______________________________________________
MEDS

______________________________________________
______________________________________________

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