28 Pa. Code § 139.29
Upon admission to a neonatal care unit, nurses shall initiate and maintain records on all infants as to weight, type and volume of feedings; time of first voiding; time of passage of first stool; number, color and consistency of stools; and temperature. If abnormalities are suspected or recognized, nurses shall also make notations on respiratory rate, dyspnea, color, cyanosis, jaundice, pallor, lethargy, twitching, motor activity, skin and buttocks, vomiting, condition of the eyes and umbilical cord, and other relevant factors as indicated and warranted by the condition of the infant. Treatments, medication and special procedures ordered by a physician should also be recorded with time, date and the name and title of the individual who administers them.
28 Pa. Code § 139.29
This section cited in 28 Pa. Code § 139.21 (relating to policies and procedures).