Date
Gestational Age (at birth & today)
Admission Dx (primary diagnosis for admission)
HPI (history of present illness)
Briefly summarize the reason for admission and current clinical status.
Include details relevant to prematurity, such as:
Respiratory status (on room air, oxygen support, ventilator)
Feeding status (enteral feeds, gavage, parenteral nutrition)
Temperature regulation (stable, needs incubator)
Developmental milestones (appropriate for gestational age?)
Any specific concerns (apnea, bradycardia, feeding intolerance)
Medications
List all current medications and dosages.
Intake & Output
Document intake (enteral feeds, IV fluids) and output (urine, stool) over the past 24 hours.
Vitals
Record vital signs (temperature, heart rate, respiratory rate, oxygen saturation).
Physical Exam
Briefly summarize findings relevant to prematurity:
General (growth parameters, weight, length, head circumference)
Respiratory (chest wall movement, breath sounds)
Cardiovascular (heart rate, rhythm, pulses)
Abdomen (distention, organomegaly)
Neurologic (muscle tone, reflexes)
Labs & Imaging
Summarize any recent laboratory tests or imaging studies (X-ray, ultrasound) and their results.
Assessment
Summarize the infant’s overall condition, including:
Current stability
Response to interventions
Progress towards developmental milestones
Any ongoing concerns
Plan
Outline the plan for the next day/days, including:
Respiratory management goals (weaning from oxygen, ventilator settings)
Feeding goals (advancing enteral feeds, starting oral feeds)
Monitoring plan (vitals, weight checks, labs)
Anticipated interventions (procedures, medications)
Discharge planning considerations (if applicable)
Education
Briefly document any education provided to the family regarding the infant’s condition and care.
Notes
Include any additional relevant information or observations.
Disclaimer: This information is for educational purposes only and should not be interpreted as medical advice. Please consult with a qualified healthcare professional for the diagnosis and treatment of preterm infants.