Placenta Process Record – Placenta Smoothie

PRN Member email address (your form will be sent to this address) *

Client's name *

Any allergies noted on Booking Form? *

Yes, please noteYes, please note

Meconium present (double check on Placenta Release Form) *

Yes - DO NOT PROCEED WITH RAW PLACENTA SMOOTHIE

Any other physical contaminants present? *

Yes - DO NOT PROCEED WITH RAW PLACENTA SMOOTHIE

Date of making smoothie (must be within 24 hours of birth) *

Time of making smoothie *

Temperature of placenta prior to processing (if not under 8°c then note in corrective actions taken box below) *

Location smoothie is being processed at *

Hands washed & Personal Protection Equipment worn (7.5) *

Yes

No, why?No, why?

Work space set up correctly (cleaned, disinfected, protected & supplies prepared) (7.1/7.12) *

Yes

No, why?No, why?

Equipment is clean, disinfected and in good working order prior to use (7.1) *

Yes

No, why?No, why?

Single use blender used *

Yes

No, why?No, why?

Raw placenta smoothie process (P1) followed *

Yes

No, why?No, why?

Receptacle for smoothie is clean and checked for damage prior to filling *

Yes

No, why?No, why?

Clean down & disinfect completed (7.1) *

Yes

No, why?No, why?

Waste management steps followed (7.11/A6) *

Yes

No, why?No, why?

Who took responsibility for the smoothie once it was prepared? *

Client

Passed to birth partner to deliver to client

Placed in client's fridge at home

OtherOther

The Client/birth partner have been made aware of the following (please tick) *

Cannot be made if any meconium present at birth

Needs to be stored under 8°c

Should be consumed immediately and within 24 hours of the time of birth

My clients are left with instructions/labels on how to look after and consume their remedy safely

Any other stipulations?Any other stipulations?

Corrective action taken

Notes