Document Hospital Course Details

You can provide information on the tests done and the medications given to the baby in the Hospital course section on the Pregnancy/Birth History template.

1. On the Intake template, click the Birth History link.
   The Pregnancy/Birth History template opens.
2. In the Hospital course section, select No or Yes for the following fields:
   

   • Vitamin K injection
   • Hep B vaccine
3. Select Pass or Fail for Hearing test.
   • If you select Fail, select Rt ear, Lt ear, or Both ears, and then select the Repeat hearing test ordered check box.
4. Enter the infant blood type and select the Rh factor.
5. To provide antiglobulin test result, click Coombs, and select any of the following options:
   • Positive
   • Negative
   • Unknown
6. Select the Jaundice option.
   • If you select Yes, click Peak bilirubin level and enter the bilirubin level using the numeric keypad.
7. Select the Phototherapy option.
   • If you select Yes, enter number of days required using the numeric keypad.
8. Select the Sepsis evaluation option.
   If you select Yes, the Positive blood culture and Antibiotics fields appear. Do the following:
   1. Select the Positive blood culture option.
   2. Enter the number of days on antibiotics in Antibiotics.
9. Select No or Yes for Fetal distress.
10. Select the Oxygen required option.
    If you select Yes, the Route and # days fields appear. Do the following:
    1. Click Route and select the route of oxygen from the list.
    2. Click # days and enter the number of days when oxygen is required.
11. Select the SpO2 measured option.
    If you select Yes, the Methodology and Time of test fields appear. Do the following:
    1. In Methodology, select the way of measuring SpO2 and enter the test result in the % field.
    2. Click the arrow next to Time of test or click the clock icon to enter the time in Hours and Mins on the Time Entry template.
12. Select the Stayed in NICU option.
    If you select Yes, the Birth Hx Nicu template opens. Do the following:
    1. Enter the number of days of stay in NICU.
    2. Select the problems from the Diagnosis list.
    3. Select the relevant options for the procedures done in NICU.
    4. Select the relevant Abnormal Studies options observed in NICU, and then enter the result for the corresponding study.
    5. Click OK to save and return to the Pregnancy/Birth History template.
       The Detail button appears on the Pregnancy/Birth History template.
    6. Click Detail to add or modify data.
13. If the newborn stayed in nursery, enter the number of days and reason.
14. Select the Birth defects option.
    • If you select Yes, enter the birth defect detail of the baby in the corresponding field.
15. Select the State screening done option.
    • If you select Yes, select a screening disorder from the corresponding list to indicate any abnormality.
16. Select theMedication given option.
    • If you select Yes, enter the medications given to the newborn in the list.
17. Select the Umbilical cord blood test option.
    • If you select Normal, click the arrow next to Time of test or click the clock icon to enter the time in Hours and Mins on the Time Entry template.
    • If you select Abnormal, click the Details button to enter additional details on the Umbilical Cord Blood Test template.
      

18. Click OK to save and return to the Pregnancy/Birth History template.
19. If applicable, select the Turner syndrome or Down syndrome check box, or both.
    Note: The selected Turner syndrome and Down syndrome options are carried forward to future encounters. The specialized growth chart for Turner syndrome is generated when you click the Growth Chart link in the Vital Signs panel. If you select the Turner syndrome check box, the system cannot generate the growth chart for weight.