UW HEALTH CLINICAL POLICY 1
Policy Title: Newborn Naming
Policy Number: 3.2.8
Category: UW Health
Effective Date: May 1, 2017
Provide a process to rapidly register an un-named newborn patient for admission to the American Family
Children’s Hospital (AFCH), the UW Hospital Emergency Department, and The American Center treatment,
or consultative services and ensure accurate identification of these patients.
Provide a process to update the newborn name in the electronic medical record (Health Link).
II. POLICY ELEMENTS
This policy establishes procedures for rapid admission of an un-named newborn and management of the
patient’s electronic medical record. This policy may be applied to infants that are in utero or recently born.
A. Naming the un-named newborn
i. In order to register the unnamed newborn in Health Link, the newborn will be named using the
following naming convention which is based on the mother’s first/last name and the gender of the
a. Newborn last name will be the same as mother’s last name, i.e. ‘Smith’
b. Newborn first name will be one word, ‘Baby plus the newborn gender’, i.e. “Babygirl” or
“Babyboy”. If the gender is unknown or ambiguous, the newborn first name will be:
c. Newborn middle name will be the mother’s first name, i.e. “Mary”
d. Using this naming convention the newborn’s name will be, “Smith, Babyboy Mary”
ii. In the case of multiple births, i.e., twins, triplets, etc., a capital letter will be used in the un-named
newborn first name, beginning with the letter A. Example:
a. Smith, BabygirlA Mary; Smith, BabygirlB Mary; Smith, BabyboyC Mary
b. Admissions will update the patient type in Health Link to “twins/multiples”
iii. In the event a Level I pregnant trauma patient presents to a UW Health Emergency Department
and is named as a “Unident” (according to UW Health clinical policy #3.2.7, Unidentified Patient)
and proceeds to delivery, the newborn will be named in accordance with this policy but using the
mother’s “Unident” name; for example:
a. Mother’s name: “XxIowa, Unidentified21”
b. Baby’s name: “XxIowa, Babygirl Unidentified21”
B. Linking mother and baby medical records when both are admitted to a UW Health hospital
i. A link between the mother and newborn chart will be made in two ways:
a. Admissions will enter the mother as the guarantor for the newborn.
b. Admissions will enter a comment in the ‘Permanent Comment’ demographic section for a
“Unident’ or non-Unident in both the mother and newborn chart
1. Unident example: Comment in mother’s chart: “Patient is the mother of XxIowa,
Babygirl Unidentified21”; comment in the newborn chart: “Baby is the daughter of
2. Non-unident example: Comment in mother’s chart: “Patient is the mother of
Smith, Babyboy Mary”; comment in the newborn chart: “Baby is the son of Smith,
C. Newborn name change in Health Link
i. Once the baby has been named by the parent(s) the unit will call Admissions to update the medical
record with the baby’s name. A physician order is not needed to update the newborn name.
a. If mother was admitted under her own name, Admissions will enter a comment in the
Permanent Comments section of the mother’s record noting the updated baby’s name.
ii. Mother and newborn are admitted as “Unident” patients:
a. A physician order in Health Link is needed to change the “Unident” mother and newborn
b. Admissions will update the mother’s name in Health Link based on the physician order.
UW HEALTH CLINICAL POLICY 2
Policy Title: Newborn Naming
Policy Number: 3.2.8
c. Admissions will notify the NICU (or Pediatric unit) that mother has been identified and her
name updated in Health Link.
d. The newborn’s physician will write an order to update the newborn name.
e. Admissions will update the newborn name in Health Link and write a note in the
Permanent Comments section of the mother’s chart with the newborn’s updated name.
Author: Access Center Manager
Senior Management Sponsor: SVP/Chief Financial Officer
Reviewers: Director, Access Services; Director, Health Information Management
Approval committees: UW Health Clinical Policy Committee
UW Health Clinical Policy Committee Approval: April 17, 2017
UW Health is a cohesive, united and integrated academic medical enterprise comprised of several entities.
This policy applies to facilities and programs operated by the University of Wisconsin Hospitals and Clinics
and the University of Wisconsin Medical Foundation, Inc., and to clinical facilities and programs
administered by the University of Wisconsin School of Medicine and Public Health. Each entity is
responsible for enforcement of this policy in relation to the facilities and programs that it operates.
Peter Newcomer, MD
Chief Clinical Officer
J.Scott McMurray, MD
Chair, UW Health Clinical Policy Committee
UW Health clinical policy #3.2.7, Unidentified Patient
VII. REVIEW DETAILS
Last Reviewed: May 2, 2017
Next Revision Due: May 2020
Formerly Known as: Hospital Administrative policy #8.35