Electronic Health Record Documentation of Nursing Care Procedures and Change in Weight of Healthy, Moderately Premature Neonates.

PURPOSE: To identify the nursing care procedures (NCPs) performed in a NICU that disrupt the thermal environment by opening the incubator of moderately preterm neonates (mPNs) (32-34 wk gestational age) and the relationship between the frequency of these disruptions and change in weight (Δwt).

DESIGN: Survey and descriptive correlational methodology.

SAMPLE: Systematically identified, published references to NCPs that opening the incubator developed an itemized list of NCPs that was used to query the electronic health records (EHRs) of 164 mPNs in the first ten days of life (DOL).

MAIN OUTCOME VARIABLE: The Δwt between birth and ten DOL.

RESULTS: Of 51 NCPs identified, 26 were represented in the EHR. A mean of 614 (range 402-1,080; SD = 137) EHR-documented NCPs that opening the incubator were recorded. The frequency of NCPs was negatively correlated with the Δwt of mPNs at ten DOL, rs (164) = -.162, p = .038.