Code: NEO.I.

01
INSTRUCTIONS FOR IDENTIFYING THE Version: V.02
NEWBORN Validity: 06/24/2022
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INSTRUCTIONS FOR IDENTIFYING THE

NEWBORN

WARNING:

This document is the property of the Clinic and may not be reproduced in whole or in part, or provided to
third parties without the knowledge and authorization of the Administrative Management or personnel
responsible for its control.

REVIEWED BY:
PREPARED BY: Head of Nursing APPROVED BY:
SGC Team Obstetric Center Medical Director
Coordinator
Karen Loredo
SGC Team Dr. Abel Garcia
Irene Rochabrun
06/10/2022 06/17/2022 06/24/2022

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INDEX

1. OBJECTIVE.............................................................................................................................
2. SCOPE.....................................................................................................................................
3. REFERENCES AND/OR LEGAL BASIS....................................................................................
4. TERMS AND DEFINITIONS.....................................................................................................
5. RESPONSIBLE.........................................................................................................................
6. POLICIES.................................................................................................................................
7. DOCUMENT DESCRIPTION....................................................................................................
8. RELATED DOCUMENT............................................................................................................
9. RECORDS................................................................................................................................
10. CONTROL OF CHANGES........................................................................................................
11. ANNEXES................................................................................................................................

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1. OBJECTIVE
Establish and implement a sole identification system for all Newborns within the
Clinic.

2. SCOPE
All care and administrative personnel of the Clinic services that provide health
care to newborns.

3. REFERENCES AND/OR LEGAL BASIS

 Law No. 26842, General Law of Health.
 Clinical practice guides for Newborn care – Peruvian Ministry of Health.
 Practical guides endorsed by the AAP (American Academy of Pediatrics).
 JCI Hospital Accreditation Standards Manual.

4. TERMS AND DEFINITIONS

a. Pelmatogram: impression of the footprint used in medical and criminal
science. Like the fingerprint, the footprint is characteristic of each person.
b. NB: Newborn
c. Servo-cradle: Heat irradiating cradle that allows immediate access to the
newborn and facilitates the completion of procedures during the first
moments of life of the baby, keeping him/her in optimal environmental
conditions.
d. Apgar Test: Evaluation of the vitality chart of a newborn (NB) carried out
when he/she has just been born, that is to say, at the 1st and the 5th minute
of life:
At the 1st minute: To evaluate how the NB arrives in the birth process.
At the 5th minute: For the pediatrician to evaluate the adaptation of the NB.
In this clinical examination the pediatrician performs a test in which 5
parameters are evaluated to obtain a first simple and clinical assessment
on the general state of the NB.
e. Pelmatoscopy: It is a discipline of Papiloscopy that deals with the study,
classification, filing and homologation of the papillary ridges found on the
palms of the feet with the purpose of identifying people; as in the case of
newborns

5. RESPONSIBLE

RESPONSIBLE RESPONSIBILITIES
 Ensure compliance with this document.
 Take action on safety incidents reported of non-com-
Medical Direction pliance with this document.
 Communicate the NB Identification instructions to the
specialist physicians and ensure its compliance.
Head of Nursing  Disseminate and ensure that all personnel in their
charge are aware of the information in this document.
Neonatology/
Obstetrics  Spread and Comply with the activities indicated in
Coordinator this document.

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6. POLICIES
None.

7. DOCUMENT DESCRIPTION
When a delivery or a cesarean occurs at the clinic, the newborn (NB) is identified
as follows:

I. Before childbirth
A) In Delivery Room and Surgical Center
Responsible Activities
1. Asks the mother the names of the NB.
2. Corroborates surnames with the patient's medical record (spelling).
3. Generates the PROVISIONAL identification wristband (filled
manually).
The wristband contains the following identifiers:
a. Newborn surnames, along with the acronym “NB”
Neonatology
Note: In multiple births the term “NB” is not used, instead a
Nursing
letter and the number of the NB are written following the order
Technician
of birth:
 For Twins: G1 and G2
 For Triplets: T1, T2 and T3
 For Quadruplets: C1, C2, C3 and C4; etc.
b. Sex, indicating the letter: F (Female) or M (Male)

II. After childbirth

A) In Delivery Room and Surgical Center

Responsible Activities
1. Receives the NB and takes him/her to the Servo-cradle.
2. Follows the immediate attention of the newborn protocol.
3. Shows the NB to the mother, indicates the sex and briefly
Pediatrician
explains to her that the adaptation period controls will be carried
out in the neonatology room or NEO ICU, according to what was
planned before delivery/cesarean section.
Neonatology 4. Perform Pelmoscopy:
Nurse a. Both feet are reflected in the "NEO.F.04 Newborn
Identification Sheet".
b. On 80-gram Bond sheet, he performs pelmatoscopy for the
Birth certificate and the index finger print of the mother's right
hand.

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Note: If the newborn's condition is critical or premature, this is done

in the neonatology service.
1. Confirms the sex of the NB.
2. Fills in the date and time of birth on the PROVISIONAL
identification wristband (filled out manually).
3. Straps on the PROVISIONAL identification wristband (filled out
manually):
 Neonatology: right hand (taking into account that it is not
Obstetrics tight)
Nurse  Neonatal ICU: stuck on the incubator.
4. The NB is referred to NEONATOLOGY/Neonatal ICU,
transportation is done with the pediatrician.

B) In neonatology service/Neonatal ICU

RESPONSIBLE ACTIVITIES
Neonatology 1. Takes anthropometric measurements, does ocular
Nurse prophylaxis and administers vitamin “K”.

2. Prepares the second - PRINTED - wristband in the thermal

printer; it will contain the following data:
a. Newborn surnames, along with the acronym “NB”.
Note: In multiple births the term “NB” is not used, instead a
letter and the number of the NB are written following the
order of birth:
 For Twins: G1 and G2
 For Triplets: T1, T2 and T3
 For Quadruplets: C1, C2, C3 and C4; etc.
b. Sex. indicating the letter: F (Female) or M (Male)
c. Medical Record Number.
d. Name of the Mother.

3. Straps the second wristband (PRINTED):

 Neonatology: right hand (taking into account that it is not
tight)
 Neonatal ICU: Stuck on the incubator

4. Does the Pelmatogram, following the steps below:

a. Lies the NB down on the servo crib.
b. Cleanses the skin on the sole of the infant's foot,
removing fat, using a gauze with 70% pure alcohol.
c. Places the NB's foot on the pad, taking special care in
the hallucal area, this is done for both feet to achieve
the proper pelmatogram.
d. Both feet are printed on NEO.F.04 Newborn identification
card.
Note: Additionally, the footprint of the right foot is taken for the
Newborn's identification card (Annex 1) and the birth certificate.

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5. Obtains the mother's right index fingerprint in her room and

completes all the information indicated in NEO.F.04 Newborn
identification card.

6. The Newborn remains in the incubator in the adaptation

period for approximately 2 hours.

C) In obstetrics service

RESPONSIBLE ACTIVITIES
1. Complete the Newborn Identification Card with the mother's
information.
2. Asks the Neonatology Service for the NB's data, such as:
Weight, Time of Birth, APGAR, Height and Sex.
3. Deliver the "NEO.F.04 Newborn Identification Form" to the
Obstetrics Nurse Neonatology Nurse for inclusion in the newborn's clinical
history and another for the Mother's clinical history.
4. Completes the Birth Certificate according to the module
available on the website of the National Registry of
Identification and Civil Status, RENIEC (Online Birth
Certificate).
Attending Physician
5. Signs Birth Certificate and stamps right index fingerprint.
(Gynecologist)

8. RELATED DOCUMENT

Name of the Document Document code

PATIENT IDENTIFICATION PROCEDURE GSA.P.01

9. RECORDS

Name of the Record Record code

Newborn identification sheet NEO.F.04

Newborn identification card S/N

Birth Certificate S/N

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10.CONTROL OF CHANGES
Date of Section(s)
Version Brief description of the change
Validity affected
05 05/21/2019 Document structure and code are modified -
JCI accreditation standards manual added 3.
Definition of “Pelmatogram” is added 4.
The entire description of the document is
5.
modified
06 09/11/2020
“Responsible” section is added 5.
“Policies” section is added 6.
It is added that the identification wristband is
7.
stuck to the incubator in NEO ICU.
07 06/24/2022 Document revision All

In this control of changes the last 3 versions will be presented

11.ANNEXES
Annex 01: Newborn Identification Card