A Guide To The NCH Notes

A guide to the NCH
notes
Helen Dyson
SpR
July 2007
Updated July 2009
by Anneli Wynn-Davies
Introduction
• The aim of this teaching

package is to ensure that you
understand the format of the
neonatal notes at NCH so that
we can create an accurate and
user friendly record of a baby’s
stay on the unit.
• The introduction of the Badger

system (see Badger guide) has
resulted in a reduction in the
amount of information written
in the medical notes and
recorded elsewhere.
Admission notes
• Ready made sets of notes, complete with a unit
number, can be found behind the nurses station.
When a baby is admitted, the next set of notes is
selected and the baby is booked in by calling the
maternity front desk (usually done by the ward
clerk). The notes and unit number can then be
used.
• On admission, the admitting doctor or ANNP

needs to:
– Carefully review the maternal notes
– Input all relevant data into the Badger system
– Print out an admission summary
– Document the resuscitation, initial examination,
assessment (including a clear problem list) and
management plan. Document discussion with
parents (see later)
• It is particularly important that all relevant

maternal, antenatal and delivery history is
captured and put into the Badger system at this
point. You can use the free text box to document
this information.
Daily notes
• All entries into the notes should be dated and
timed in 24 hour clock format
• A daily review of each baby should be
documented. This should include the baby’s
current weight, age and corrected gestation, a list
of relevant problems and a systematic review of
the current clinical condition. A full examination
should also be documented.
• The doctor or ANNP reviewing a baby needs to
– Complete a daily summary
– Make a provisional plan for the day (this will be
reviewed on the ward round)
– Update the Badger data for that day (see Badger
guide)
Daily Review – suggested format
• Age in days
• Gestation and corrected gestation
• Birth weight and current weight
• Problems – up-to-date problem list
• Systemic review – Respiratory
Cardiovascular
Fluids
Sepsis
Neurological
Metabolic
Lines
Medications
• Clinical examination
• Plan
Results sheets
• Blood gases:
– Blood gas results are recorded on a flow sheet kept
at the bedside. When you write a result on the chart
you must ask a nurse or doctor to countersign the
entry as this will reduce transcription errors. There
is space on the chart for you to document your
plan, including when the next gas is due. All gases
are kept in the envelopes under the babies charts.
• Haematology / Biochemistry results:

– All results need to be documented in the flow sheet
in the medical notes. Bloods are usually done in the
middle of the night shift so that results are available
for the morning round. The night SHO should
ensure that all results are written in and any
problematic or outstanding results highlighted on
the handover round. The daytime team are
responsible for recording any results they receive
during the day.
– A Bilirubin chart is also kept in the medical notes.
• Microbiology results
– When a microbiology test is sent, this needs to be
documented on the microbiology sheet in the
medical notes. There is then space for the results
and sensitivities to be recorded. This system allows
us to easily review microbiology results.
Other
Family information sheet
– This section of the medical notes is used by all members
of the healthcare team to document any relevant social
history. If there has been contact with social services or
the health visiting team, information relevant to the care of
the baby will be recorded here.
Contact with parents sheet

– Any communication with parents should be recorded in
this section of the notes. It is most often used for
documenting discussions around the time of delivery or
when there have been other updates about the condition
of the baby. The conversation ought to be documented by
the person speaking to the parents. If you are on a ward
round where the consultant or SpR is updating parents
then you may want to make a note of the conversation in
this section – please ask if you are not sure what to write.
Low Dependency weekly summary

- These should be completed on a Monday morning
and include a summary of the previous weeks
progress, examination and plans for the week.
Opthalmology page
- Please leave this blank as this is where Mr.
Gregson will document ROP screening.
Discharge
• When a baby is discharged, the Badger
system allows us to create a discharge
letter (see Badger guide). However, the
quality of this letter relies upon the quality
of the data inputted. There is adequate
free text space for us to ensure high
quality letters are produced.
• All babies discharged directly from the

neonatal unit must have a discharge
letter completed, printed and signed
before they go home.
• The doctor or ANNP completing the

discharge letter also need to ensure that
appropriate follow-up has been arranged.
Postnatal wards
• For many babies reviewed on the post natal
wards, a short entry in the maternal notes (on the
baby page) is adequate. However, any baby
receiving transitional care or more than one
review needs to have their own set of medical
notes. These are made up by the ward clerks on
the postnatal wards. Notes kept behind the nurses
station on the neonatal unit must not be used for
this purpose.
• The ward clerks have been asked to put a copy of

the maternal blue/green delivery summary into the
baby’s notes. For many babies, this will provide
adequate maternal, antenatal and deliver history.
However, it is important that for babies being
referred to another specialty or coming to the
neonatal follow up clinic, any additional detail
from the maternal notes be written in by the
reviewing SHO.
• If you see a baby on the postnatal ward you need

to put your name on the notes tracking sheet at
the front of the notes. This allows the notes to be
redirected to you after the baby’s discharge for
completion of referral or discharge letters. Any
baby needing more than standard postnatal ward
care probably needs a short letter to the GP.
Please ask if you are unsure about whether a
letter is needed.
Badger
• Badger is the electronic system used by many neonatal
units. It allows data to be collected on a daily basis and
generates admission and discharge documentation
• Badger calculates daily levels of care and is the way
the neonatal unit receives payment for activity.
• The data is only as good as the data inputted.
• There are 4 areas in which data needs to be put into
the Badger system
1) On admission – All forms relating to admission need
to be completed, including initial examination.
2) Daily entries – Daily updates should be put in by the
Doctor/ANNP reviewing the baby
3) Weekly updates – The clinical summary of stay
should be updated weekly. This then ensures that
discharge summaries are accurate and easily
completed
4) Discharge – At discharge the clinical summary of
stay should be checked and updated and the discharge
summary completed. Please ensure at this time that all
daily updates are complete and that there are no data
problems (red crosses for problems and green ticks
when resolved).

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A guide to the NCH

• The aim of this teaching

• The introduction of the Badger

• On admission, the admitting doctor or ANNP

• It is particularly important that all relevant

• Haematology / Biochemistry results:

Contact with parents sheet

Low Dependency weekly summary

• All babies discharged directly from the

• The doctor or ANNP completing the

• The ward clerks have been asked to put a copy of

• If you see a baby on the postnatal ward you need

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