NICU Admission Note

Valmis sissekanne

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.

Illustratiivne juhtum väljamõeldud patsiendiandmetega. See ei ole päris patsienditoimik ega kliiniline juhis. Kontrolli iga sissekannet oma vastuvõtu põhjal.

Sissekande aluseks olevad kliinilised faktid

Korduskasutatav mallistruktuur

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]