Patient: [Patient Name]
MRN: [Medical Record Number]
Date: [Date of Birth]
Time: [Time of Delivery]
Resuscitation Team:
Attending Physician: [Name]
Resident Physician: [Name] (if applicable)
Neonatal Nurse Practitioner: [Name] (if applicable)
Nurse: [Name(s)]
Respiratory Therapist: [Name] (if applicable)
Apgar Scores:
1 minute: [Score]
5 minutes: [Score]
Delivery Information:
Gestational Age: [Weeks]
Birth Weight: [Grams]
Mode of Delivery: [Vaginal / Cesarean Section]
Presentation: [Vertex / Breech / Other]
Anesthesia: [Type / None]
Complications (if any): [List any complications during delivery that may
impact resuscitation efforts, e.g., meconium aspiration, shoulder dystocia]
Resuscitation Initiated:
[Yes / No] (Indicate if resuscitation efforts were required)
Resuscitation Measures:
Airway:
Meconium aspiration (if present): [Yes / No]
Suctioning: [Oropharyngeal / Nasopharyngeal]
Bag-mask ventilation: [Yes / No]
Endotracheal intubation: [Yes / No] (if used, document time)
Breathing:
Oxygen administration: [FiO2 %] (fraction of inspired oxygen)
Mechanical ventilation: [Yes / No] (if used, document settings)
Circulation:
Chest compressions: [Yes / No] (if used, document duration)
Umbilical cord milking: [Yes / No]
Epinephrine administration: [Yes / No] (if used, document dose and route)
Volume expanders: [Yes / No] (if used, document type and volume)
Medications:
List any other medications administered during resuscitation (e.g., naloxone)
Doses and routes of administration
Outcome:
Spontaneous respirations established: [Time]
Stable vital signs achieved: [Time]
Admission to NICU: [Yes / No] (if yes, briefly state reason)
Additional Notes:
Document any other significant observations or interventions during resuscitation.
Briefly describe the infant’s condition after resuscitation is completed.
Follow-up:
Plan for ongoing monitoring and management of the infant (e.g., serial blood gas analysis, chest X-ray).
Disclaimer: This template is for informational purposes only and should not be used as a substitute for professional medical advice. The specific details of a neonatal resuscitation will vary depending on the individual infant and the circumstances of delivery.