High-Risk Infant Follow-Up Clinic Note

High-Risk Infant Follow-Up (HRIF) Clinic Visit

Date of Service: [date]

Patient: [name, MRN, DOB]

Chronological Age: [age]

Corrected Age: [age] (GA at birth: [weeks + days])

Birth/NICU Summary: [gestational age at birth, birth weight, major NICU diagnoses, key interventions, discharge date]

Accompanied by: [caregiver name(s), relationship(s); interpreter: [language / none]]

Information Sources: [caregivers providing history]; [records reviewed with date range] (Throughout this note, label sources as: Caregiver report, Observed today, or Records reviewed.)

Interval History

Reason for visit and caregiver concerns: [caregiver's stated reason and top concerns in 1–2 sentences; use direct quote when helpful] (Caregiver report)

Interval events: [hospitalizations, ED visits, significant illnesses since last HRIF visit or NICU discharge; include dates and outcomes] (Label source for each item.)

Subspecialty updates: [key findings and plans by specialty] (Label source.)

Current medications: [medications with doses, routes, indications] (Label source.)

Equipment/DME: [oxygen, monitors, feeding tubes, supplies] (Label source.)

Respiratory baseline: [supports, typical symptoms, saturations, triggers] (Label source.)

Feeding changes: [changes since last visit, current tolerance/skills] (Label source.)

Immunizations: [status and any relevant prophylaxis] (Label source.)

Information gaps: [unknown or unavailable information; plan to obtain] (Include only if applicable.)

Growth & Nutrition

Age basis for growth interpretation: [corrected age / chronological age]

Growth chart standard: [Fenton / INTERGROWTH-21st / WHO / CDC / other]

Measurements today: Weight: [value] ([percentile or z-score]); Length: [value] ([percentile or z-score]); Head circumference: [value] ([percentile or z-score]) (Observed today)

Growth trajectory: [trend across prior visits; note catch-up growth, plateaus, or concerning decelerations]

Current feeding regimen: [route(s), type(s), volumes, frequency, fortification, estimated total intake] (Label source.)

Feeding tolerance and skills: [coordination, endurance, emesis/reflux, aspiration signs, supports] (Label source.)

Supplements: [vitamins, minerals, other additives] (Label source.)

Nutrition assessment and plan: [interpretation of adequacy; concerns; changes to regimen; referrals; monitoring plan]

Development & Neurosensory

Age basis for developmental expectations: [corrected age / chronological age]

Developmental surveillance: (Summarize both caregiver report and clinic observations; label source for each statement.)

• Gross motor: [skills, symmetry, movement quality, tone]
• Fine motor: [reach, grasp, hand use, bimanual skills]
• Language/communication: [receptive and expressive skills, gestures, vocalizations]
• Cognitive/play: [attention, problem solving, play skills]
• Social-emotional: [engagement, reciprocity, state regulation]

Neurologic/motor exam: [posture, head control, axial/appendicular tone, reflexes, movement quality, asymmetries] (Observed today)

Standardized screening/testing: [tool name, age basis used, scores with interpretation, validity limitations] (Include only if performed this visit.)

Autism screening: [tool, age basis, result, interpretation, follow-up plan] (Include when age-appropriate.)

Vision: [ROP history if applicable; last ophthalmology exam date and findings; current concerns; next follow-up] (Label source.)

Hearing: [newborn screen result; diagnostic audiology results; amplification status; current concerns; next follow-up] (Label source.)

Therapies and Early Intervention: [EI enrollment status; services, frequency, providers; goals; access barriers] (Label source.)

Psychosocial: [caregiver concerns, support system, resource needs, safety considerations] (Caregiver report)

Deferred assessments: [assessment not completed; reason; plan to complete] (Include only if applicable.)

Assessment

[Integrated 1–3 sentence summary capturing medical complexity, growth/nutrition status, respiratory baseline, and developmental trajectory]

Active problems:

• [Problem name] — [current status/trajectory]
• [Problem name] — [current status/trajectory]
• (Add additional problems as needed.)

Plan

(Organize by problem. For each, include interventions today, monitoring plan, and referrals with responsible party and timeframe.)

[Problem 1]: [interventions today; monitoring plan; referrals/consults with urgency and who will schedule]

[Problem 2]: [interventions today; monitoring plan; referrals/consults with urgency and who will schedule]

(Add additional problems as needed.)

Return precautions: [specific signs/symptoms; when to contact PCP/HRIF vs seek emergency care]

Next HRIF visit: [timeframe] (Note assessments to complete and any prerequisites.)

Additional follow-up: [other appointments with timeframe and responsible party for scheduling]