Document No.

NEONATAL INTENSIVE
CARE UNIT ACEMCTUG-NSD-NICU-04-001-00

Address: PALLUA ROAD, BRGY. PALLUA NORTE, TUGUEGARAO CITY Tel No.: (078) 825 0527 Page 1 of 1

BABY HAND OVER SHEET

Name:______________________________________________________ PIN: _________________________

Sex: _____________ Date of Birth: _____________________ Time of Birth: ________________

Type of Delivery: ______________________

Birth Weight: _________________________ Birth Length: ______________________

HC: _______________ CC: _________________ AC: ___________________

Meconium: [ ] PASSED [ ] NOT PASSED

Urine: [ ] PASSED [ ] NOT PASSED

Maternal Blood Group:

Maternal Risk Factors:

Assessment at Birth:

APGAR Score: _____________

Given Not Given

Injectable
Vitamin K:
Hep. B
BCG
Ointment
Erythromycin

REMARKS:

Endorsed by: Received by:

________________________________ ________________________________
Signature Over Printed Name Signature Over Printed Name