Skin to Skin Smart Phrase/.phrase Documentation in Electronic Medical Record

Below is a editable smart phrase to use when taking a baby out for skin to skin (.skinout) and back in bed (.skinback).  The ???? below would be replaced in your .phrase with the code associated with each item for auto population.


Girl A Kanga Roo out for skin-to-skin with {PARENTS:????} using {STANDING/SUPINE/SITTING – AMB:????} transfer method.

Parent and infant in a reclined position in the skin to skin chair, with skin to skin wrap securely placed around both parent and infant.

Prior to initiation of skin-to-skin, patient’s baseline axillary temperature was ***.


Girl A Kanga Roo transferred back to Incubator using {STANDING/SUPINE/SITTING:AMB:???}

You can add tolerance to skin to skin in smart phrase above to be edited, or consider leaving that information in the flowsheet i.e. respiratory rate, 02, etc.

You can utilize your flow sheet section “Environment of Care” to reflect when the infant is held skin to skin or not. for example:
_ Crib
_ Incubator
_ Parent holding
X Skin to skin holding

Then when they return to bed it is documented in same area.

You can also do it in a smart text so the timeframe of when your note is entered is when it is initiated and when put back and use second smart phrase that reflects time put back. If you are auditing, (which hopefully you are) it is nice to have a place or column to simply have the time calculated so is easy to audit versus having to “do the math” i.e. instead of documenting pt out at 10:42 and back 11:24-go ahead and document held skin to skin for 42 minutes.