Umbilical Cord Care Record Form
Document and monitor essential details of umbilical cord care for infants. Please complete all fields accurately.
Infant's Full Name
*
First Name
Last Name
Infant's Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Date and Time of Cord Care
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Care Provider Name
*
Cord Appearance
*
Normal (dry, clean, no odor)
Redness
Swelling
Discharge
Other
Cleaning Method or Product Used
*
Signs of Infection or Concern Observed
*
Redness
Swelling
Foul odor
Pus/discharge
Bleeding
None observed
Other
Instructions Given to Parent/Caregiver
*
Follow-up/Next Review Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Additional Notes or Comments
Submit Record
Should be Empty: