Newborn Daily Progress Note

Date/Time: [date and time of note]

Infant: [name], [MRN], [DOB], [sex]

Day of Life (DOL): [calculated DOL]

Gestational Age at Birth: [weeks+days] (Note source if uncertain or transferred.)

Location/Service: [unit / service]

Provider: [author name and role]

Summary

[1–2 sentence clinical summary: DOL, GA, overall stability, current weight with percent change from birth, feeding modality and adequacy, active issues driving management]

Interval History

[Narrative of interval since last assessment: overnight events, feeding history with type/frequency/effectiveness, lactation consult input if applicable, void and stool counts, parental concerns, new maternal lab results affecting newborn care] (If no interval changes, explicitly state there were no acute events.)

Objective

Weight: Birth: [birth weight]; Current: [current weight]; Change: [percent change %]

Vitals: T [temperature]; HR [value]; RR [value]; SpO₂ [value%] on [room air / respiratory support with settings]

Exam: [General appearance and tone; skin color and jaundice extent; heart sounds and pulses; respiratory effort and breath sounds; abdomen and umbilical stump; other pertinent findings by system]

Labs/Studies: [Bilirubin value] via [TcB / TSB] at [time], [HOL] HOL; [distance to phototherapy threshold per nomogram]; [glucose, blood type/DAT, other studies as applicable] (If no new labs, state so and reference most recent bilirubin with HOL if relevant to discharge planning.)

Assessment & Plan

[Synthesis paragraph: overall clinical status, weight trajectory interpretation, feeding adequacy based on transfer and output, jaundice risk status relative to treatment threshold]

Problem-oriented plan (Include only active/relevant problems):

• Feeding: [breastfeeding support plan, lactation consult status, supplementation triggers and plan if applicable, frequency targets]
• Weight/Hydration: [weight monitoring frequency, interventions if weight loss concerning or output low]
• Hyperbilirubinemia: [next bilirubin timing with rationale, phototherapy status if applicable with rebound check plan, outpatient follow-up arrangement if nearing discharge]
• Other active issues: [infection risk monitoring / hypoglycemia protocol / murmur evaluation / circumcision care / social needs as applicable]
• Discharge criteria: [feeding adequate, weight trajectory acceptable, bilirubin plan in place, screens complete or follow-up scheduled, PCP appointment confirmed]

Screening & Prophylaxis Status

• CCHD Screen: [date/time], [HOL] HOL, [pass / refer / pending / not yet due]
• Hearing Screen: [date/time]; Right: [pass / refer / pending]; Left: [pass / refer / pending]
• Metabolic Screen: [collected date/time / not yet due / repeat needed: reason and plan]
• Vitamin K: [given date/time/route / declined with counseling documented]
• Eye Prophylaxis: [given date/time/agent / exception documented]
• Hepatitis B Vaccine: [given / declined / deferred]; Maternal HBsAg: [positive / negative / unknown] (If positive/unknown or vaccine declined/deferred, document follow-up plan.)
• PCP Follow-up: [appointment date/time/location / instructions provided]

(Use explicit statuses for items not yet performed: not yet due, ordered/pending, or declined with counseling documented. If any screening incomplete at discharge, document reason, follow-up plan, and responsible party. For exclusive breastfeeding, document frequency and clinical adequacy markers rather than volumes.)