Neonatal Sepsis Risk Evaluation Note (Early-Onset Sepsis)

Infant Name/MRN: [Infant identifier]
DOB/Time of Birth: [Date and exact time of birth]
Hours of Life (HOL) at Evaluation: [HOL at time of evaluation]
Location: [L&D / nursery / NICU]
Gestational Age: [Weeks/days]
Birthweight: [Weight with units]
Maternal Identifier: [Maternal name/MRN or reference per local policy]
Author/Role: [Author name and role]
Date/Time of Note: [Date and clock time]
Exam Time: [Clock time if different from signing time]

Reason for Evaluation

[Brief reason for EOS risk evaluation including specific trigger, infant's current clinical status category, and HOL] (1–3 sentences.)

Data Availability

[Data completeness statement: maternal intrapartum record status, placental pathology if relevant, any key elements listed as "Unknown / not available"] (Label data sources such as "per OB delivery note," "per maternal MAR," or "direct exam.")

Maternal and Intrapartum Risk Factors

• GBS status: [Positive / Negative / Unknown]; [Test date if known]
• Intrapartum antibiotics: [Agent(s)]; [Start time]; [Time from first dose to delivery]; [Indication: GBS prophylaxis / broad-spectrum for suspected infection / surgical prophylaxis]
• Maternal temperature: [Highest intrapartum temperature] at [time]; [persisted / resolved]
• Intraamniotic infection concern: [None / Isolated maternal fever / Suspected / Confirmed]; [Supporting criteria if present: maternal leukocytosis, fetal tachycardia, purulent drainage]
• Rupture of membranes: [ROM date/time]; [Delivery date/time]; [Calculated duration in hours]; [PROM / PPROM if applicable]
• Delivery factors: [Mode of delivery]; [Meconium: yes / no]; [Amniotic fluid character if abnormal]; [Resuscitation summary if beyond routine]

Infant Clinical Status and Examination

Assessment time: [Clock time] ([HOL])

• Clinical status classification: [Well-appearing / Equivocal / Clinical illness]; [Symptom onset time if present]; [Status change since birth]
• Vital signs: Temp [value], HR [value], RR [value], SpO2 [value]; [Respiratory support: room air / O2 / CPAP / ventilator]; [Perfusion: cap refill, pulses]; [BP if obtained]; [Glucose if relevant]
• Focused exam: [General/neuro findings]; [Respiratory findings]; [Cardiovascular findings]; [Skin findings]; [GI/feeding if relevant]

Risk Stratification Method and Results

Method used: [Multivariate EOS calculator / Categorical risk-factor algorithm / Serial physical examination strategy]

If multivariate EOS calculator: [Calculator name/version]; Baseline incidence [value per 1000]; Inputs: GA [value], Tmax [value], ROM [hours], GBS [status], antibiotics [type/timing], exam [category]; Results: risk at birth [value per 1000], post-exam risk [value per 1000], recommendation [category]. (If any input unknown, document assumption applied or that calculator was not used.)

If categorical algorithm: [Algorithm name/version]; [Threshold criteria met]; [Resulting management category].

If serial exams/enhanced observation: [Exam and vital sign frequency]; [Observation duration]; [Escalation criteria per protocol].

Diagnostics

• Blood culture: [Obtained / Not obtained]. If obtained: [Time (HOL and clock)]; [Site]; [Volume if known]; [Before antibiotics: yes / no]; [Culture tracking plan]. If not obtained: [Reason].
• CBC/inflammatory markers: [Obtained / Not obtained]. If obtained: [Indication]; [Timing relative to birth]; [How results will guide management]. (Note if abnormal markers alone will not prolong antibiotics without culture confirmation.)
• Lumbar puncture: [Performed / Deferred]. If performed: [Time]; [Indication]. If deferred: [Reason]; [Contingency plan].
• Urine culture: [Not indicated for EOS <72 HOL / Obtained with justification]

Assessment

[Problem-oriented synthesis: infant's clinical category and trajectory, EOS risk stratification result, competing explanations for symptoms if present, diagnostic uncertainty if applicable] (2–4 sentences.)

Plan

• Antibiotics: [Started / Deferred]. If started: [Indication]; [Regimen and route]; [Start time]; [Blood culture confirmed prior: yes / no]; [Stop criteria: culture review at 36–48h, clinical criteria to discontinue, exceptions for extended therapy]. If deferred: [Rationale]; [Triggers to initiate].
• Monitoring: [Location: couplet care / nursery / NICU]; [Vital sign frequency and duration]; [Provider exam cadence]; [Responsible clinician/team].
• Escalation criteria: [If/then statements for clinical deterioration and corresponding actions: reclassify status, obtain blood culture, start antibiotics, perform LP if indicated].
• Communication: [Family discussion documented]; [OB–neonatal communication]; [Discharge counseling if observation pathway].
• Follow-up: [Next reassessment time]; [Blood culture review timepoint]; [Repeat risk stratification if status changes]; [Handoff instructions].

(Use clock times and HOL for all time-sensitive elements. Document unavailable data as "Unknown / not available" rather than omitting. Minimum required elements if time-pressured: HOL at assessment, key maternal risk factors, infant status with vitals, risk stratification method and result, antibiotic decision with monitoring plan and escalation triggers.)