NICU Discharge Summary

Note complétée

Discharge Diagnosis:
- Prematurity at 35 weeks’ gestation
- Feeding immaturity, improving

MATERNAL & PREGNANCY HISTORY:
- Maternal demographics: 29 years, G2P1
- Pregnancy complications: spontaneous preterm labor
- Maternal medications: antenatal corticosteroids
- Gestational diabetes: No; PIH: No; GBS: Negative
- Serologies: Rubella immune; HIV, hepatitis B, syphilis, and GC/CT negative
- Blood type: O positive, antibody screen negative

LABOUR & DELIVERY HISTORY:
- Vaginal delivery after spontaneous labor; clear fluid
- Brief tactile stimulation; Apgars 8 and 9

FAMILY & SOCIAL HISTORY:
- No pertinent family history reported; parents have stable housing and report no smoke exposure

CLINICAL COURSE AT NICU:
- Respiratory: Stable in room air
- Cardiovascular: Hemodynamically stable, no murmur
- Nutrition: Advanced to oral feeds and tolerating them
- Neurological: Appropriate tone and activity; no seizures
- Infection: Cultures negative; antibiotics not continued

DISCHARGE EXAM:
- Weight 2.25 kg; alert, well perfused, lungs clear, abdomen soft, normal tone and spontaneous movement

INVESTIGATIONS:
- Newborn screen collected; no imaging indicated

ASSESSMENT AND PLAN:
Newborn with prematurity and improving feeding immaturity, stable for discharge after demonstrating adequate oral intake and temperature control.
- Continue feeds every 3 hours as reviewed with family
- Track intake and wet diapers
- Hearing screen passed; metabolic screen pending

FOLLOW UP:
- Primary care visit within 2 days
- Seek urgent assessment for fever, breathing difficulty, poor feeding, or reduced urine output

Cas illustratif avec des informations patient inventées. Il ne s’agit ni d’un dossier patient réel ni d’un conseil clinique. Vérifiez chaque note au regard de votre propre consultation.

Faits cliniques à l’origine de la note

Structure du modèle réutilisable

INPATIENT NICU DISCHARGE SUMMARY  

Admitting Physician: [Name]  
Discharging Physician: [Name]  

Discharge Diagnosis:
(hyphenated list)
- [Primary diagnosis]
- [Secondary diagnosis (if any)]

MATERNAL & PREGNANCY HISTORY:
(hyphenated list)
- Maternal demographics: [Age, Gravida/Para]
- Pregnancy complications: [e.g., complication, date/intervention]
- Maternal medications:
  - [Medication name, dose, route, timing]
  - [Additional medication details]
- Gestational diabetes: [Yes/No; details if yes]
- PIH (pregnancy‐induced hypertension): [Yes/No]
- GBS status: [Positive/Negative; date if tested]
- Serologies:
  - Rubella: [immune/non‐immune; vaccine date if applicable]
  - HIV: [status]
  - Hepatitis B: [status]
  - Syphilis: [status]  
  - Chlamydia/Gonorrhea: [status]  
- Blood type and antibody screen: [Type, result]  

LABOUR & DELIVERY HISTORY:  
(hyphenated list)  
- Delivery method: [e.g., SVD, C‐section (type) and indication]  
- Date and time of birth: [MM/DD/YYYY HH:MM AM/PM]  
- Rupture of membranes: [spontaneous/artificial; date/time]  
- Amniotic fluid: [description]  
- Resuscitation details: [e.g., suctioning, PPV, CPAP, medications]  
- APGAR scores:  
  - 1 min: [score]  5 min: [score]  10 min: [score (if recorded)]  
- Cord blood gases (if obtained):  

FAMILY & SOCIAL HISTORY:  
(hyphenated list)  
- Family history:  
  - [Condition 1]: [relation and details]  
  - [Condition 2]: [relation and details]  
- Social history: [e.g., household environment, exposures, substance use]  

CLINICAL COURSE AT [Facility Name]:  
(hyphenated list)  
- Respiratory: [support provided, settings, weaning details, current status]  
- Cardiovascular: [hemodynamics, murmurs, inotropes if any]  
- Gastrointestinal/Nutrition: [feeding method, volumes, tolerance, labs]  
- Neurological: [tone, activity, seizures if any]  
- Hematology: [stability, transfusions if any]  
- Infection/Sepsis evaluation: [risk factors, cultures, antibiotics]  

DISCHARGE EXAM:  
(hyphenated list)  
- Newborn parameters:  
  - Birth weight: [g]  
  - Birth length: [cm]  
  - Birth head circumference: [cm]  
  - Discharge weight: [g]  
  - Discharge length: [cm]  
  - Discharge head circumference: [cm]  
- General: [appearance, behavior]  
- HEENT: [head shape, fontanelles, ears, palate, red reflex]  
- Respiratory: [support at exam, auscultation findings]  
- Cardiovascular: [heart sounds, murmurs, perfusion, pulses]  
- Abdomen: [softness, distension, bowel sounds, umbilical cord]  
- Genitourinary: [external genitalia, patency]  
- Skin: [color, rashes, lesions]  
- Musculoskeletal: [hip/Ortolani, spine, extremities]  
- Neurological: [tone, reflexes, movements]  

INVESTIGATIONS:  
(hyphenated list)  
- Imaging:  
- Laboratory studies:  


ASSESSMENT AND PLAN:  
(in paragraphs and hyphenated list)  
[Brief narrative summary of current status, diagnoses, and hospital course.]  
Plan:  
- [Intervention or monitoring item #1]  
- [Intervention or monitoring item #2]  
- [Intervention or monitoring item #3]  
- Screening:  
  - Hearing screen: [completed/pending]  
  - Newborn metabolic screen: [completed/pending]  
  - [Other screening or vaccination status]  

FOLLOW UP:  
(hyphenated list)  
- Primary Care Provider: [Name/arrangement]  
- Specialty follow‐up: [e.g., cardiology at # wks]  
- Additional recommendations: [e.g., feeding support, home oxygen prep]