NICU Admission Note

Completed note

Gestational Age: 34 weeks
Day of Life: 0
Reason for Admission: Prematurity and observation for respiratory transition.

Maternal History:
- Serologies: Prenatal screening reviewed; no concerns reported.
- GBS: Unknown at admission.
- ABO group and antibody screen: Reviewed; no incompatibility concern reported.

Antenatal Imaging:
- ROM: Membranes ruptured shortly before delivery.
- Maternal fever: None reported.
- Antepartum antibiotics: Given per obstetric record.

Complications During Pregnancy: Preterm labor.

Family Social History:
- Substance Use: No exposure reported.
- Mental Health: Not discussed.
- CAS Involvement: Not reported.

Delivery History:
- Gestational Age: 34 weeks.
- Antenatal Steroids Given: Yes.
- MgSO4 Given: Unknown.
- Infant delivered by: Vaginal delivery.
- Resuscitation: Drying and stimulation; no advanced support documented.
- APGARs were 8 at 1 minute and 9 at 5 minutes.
- Birth Weight: 2,200 g.
- Birth Length: 45 cm.
- Birth Head Circumference: 31 cm.

Physical Exam:
- General: Awake, active, no apparent distress.
- HEENT: Fontanelles soft and level; palate intact.
- Resp: Room air; no increased work of breathing; breath sounds clear.
- CVS: Normal S1/S2; no murmur; capillary refill under 3 seconds.
- Abdo: Soft, non-distended, active bowel sounds.
- GU: External genitalia appropriate for sex.
- Skin: Pink; no rash noted.
- MSK: Spine intact; Barlow/Ortolani normal.
- Neuro: Active with symmetric movement and age-appropriate tone and reflexes.

Surveillance:
- Newborn screen: Arrange per routine schedule.
- Hearing screen: Before discharge.
- Head US and ROP screening: Assess eligibility by gestational age and birth weight.

Immunizations:
- RSV prophylaxis: Assess eligibility.
- Routine immunizations: Plan according to age and local schedule.

Assessment & Plan:
Preterm newborn admitted for monitoring and support during transition.

1) Prematurity
- Monitor temperature, feeding, glucose, and respiratory status per unit protocol.
- Review maternal infection risk and pending screening.
- Support family and provide updates; reassess need for respiratory support.

Illustrative case with invented patient details. This is not a real patient record or clinical guidance. Review each note against your own consultation.

Clinical facts behind the note

Reusable template structure

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]