NICU Discharge Summary

Voltooide notitie

Voorbeeld — gegenereerd door Notat uit een voorbeeldconsult

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™

Sjabloon

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]