NICU Admission Note

Fertige Notiz

Beispiel — von Notat aus einem Beispielbesuch generiert

Reason for visit:
Three-day history of fever, runny nose, and reduced appetite. Drinking fluids and passing urine normally.

Assessment:
Likely uncomplicated viral upper respiratory infection. Child is alert and clinically stable today.

Plan:
Supportive care and fluid intake advised. Parent given clear safety-netting for breathing difficulty, dehydration, or persistent fever.

Clinical documentation:
Relevant symptoms, meaningful negatives, assessment, and follow-up advice were captured from the sample visit and organised into the selected template.

FactsContext™

Vorlage

NICU Admission Note

Gestational Age:
Day of Life:
Reason for Admission:

Maternal History:
- Serologies: rubella, syphillis, Hep B, HIV
- GBS:
- ABO group and antibody screen:

Antenatal Imaging:
- ROM:
- Maternal fever:
- Antepartum antibiotics:

Complications During Pregnancy:

Family Social History:
- Substance Use:
- Mental Health:
- CAS Involvement:

Delivery History:
- Gestational Age:
- Antenatal Steroids Given: [Yes/No/Unknown]
- MgSO4 Given: [Yes/No/Unknown]
- Infant delivered by:
- Resuscitation:
- APGARs were [#[ at 1 minute and [#] @ at 5 minutes

- Birth Weight:
- Birth Length:
- Birth Head Circumference:

Physical Exam: 
- General: Awake, active, in no apparent distress
- HEENT: Normocephalic. Fontanelles soft and level. External ears WNL. Palate intact. Non-dysmorphic. Red Reflexes: Deferred
- Resp: On room air at time of assessment. No cyanosis. GAEB. No adventitious breath sounds. No increased WOB.
- CVS: Normal S1/S2. No audible murmurs or EHS. CRT <3s. Femoral pulses strong and equal. 
- Abdo: Soft, non-distended, active bowel sounds
- GU: External [gender] genitalia.
- Skin: Pink. No rashes noted. 
- MSK: Barlow/Ortolani normal. Spine intact. 
- Neuro: Awake, active, reactive. Moving all extremities symmetrically. Tone central and peripheral WNL. Normal and symmetric moro, palmar/plantar grasp and suck reflexes.  

Surveillance:
- Newborn Screen Date(s):
- Repeat Newborn Screen at 3 Weeks (< 1500gr or < 33 weeks):
- Hearing Screen:
- Head US:
- Retinopathy of Prematurity (< 1250gr or < 30+6 weeks): 
- Bone panel (Ca, P, ALP), CBC, Ferritin (at 3 weeks):

Immunizations:
- RSV prophylaxis: 
- Pediacel at 60 days of age
- Prevnar 13 at 60 days of age

Assessment & Plan:
(Use medical terminology if appropriate)
[One-sentence patient summary including age, sex, and primary diagnosis if not redundant]

#) [Assessment as a numbered item] 
- [Hyphenated list with each corresponding plan item on a new line]