Newborn Discharge Summary

Infant name: [Infant full name]

MRN: [Medical record number]

Date of birth (with time): [DOB, birth time]

Sex: [female / male / intersex / unknown]

Gestational age at birth: [Gestational age in weeks+days]

Birth hospital/unit: [Hospital name and unit]

Admission (birth) date/time: [Date and time]

Discharge date/time: [Date and time]

Medical home: [PCP/clinic name, contact info, appointment scheduled: yes/no] (If scheduled, include date/time/location; if not, specify who will schedule and by when.)

Discharging clinician: [Name, credentials/role]

Reason for Hospitalization

[Brief reason for admission] (For routine newborns: birth hospitalization after delivery at [gestational age]. For complicated courses: include primary indication(s) such as prematurity, respiratory distress, hypoglycemia, or sepsis evaluation.)

Disposition

[home with parents / transfer to another facility / foster placement] — [stable / guarded]. [One-line rationale supporting condition assessment.]

Birth & Delivery Summary

Gestational age: [Weeks+days]

Birth weight: [g]

Birth length: [cm]

Birth head circumference: [cm]

Mode of delivery: [spontaneous vaginal / assisted vaginal / cesarean] (Include indication if cesarean or assisted.)

Rupture of membranes: [duration in hours] (Include if prolonged or clinically relevant.)

Amniotic fluid: [clear / meconium-stained / bloody / unknown] (Include only if abnormal or clinically relevant.)

Maternal intrapartum fever/chorioamnionitis: [present / absent / suspected / unknown]

Apgar scores: 1 min [score], 5 min [score], 10 min [score] (Include 10-minute score only if documented.)

Resuscitation: [none / routine drying and stimulation / PPV / CPAP / intubation / chest compressions / medications] (List all interventions that were required.)

Initial status: T [temp], HR [rate], RR [rate], SpO2 [%]; Initial glucose [mg/dL] (if indicated); Respiratory support [room air / supplemental O2 / CPAP / mechanical ventilation]

[Brief 1–3 sentence narrative of delivery room course] (Include only if complications or key decisions occurred.)

Relevant Maternal/Perinatal Information

• Maternal blood type/Rh and antibody screen: [Blood type, Rh], antibody screen [positive / negative / unknown] (Include if relevant to hemolysis or jaundice risk.)
• Maternal HBsAg status: [positive / negative / unknown] — Source: [prenatal labs / delivery record / other] (If unknown, document actions taken, interim management, and follow-up plan with responsible party.)
• GBS status: [positive / negative / unknown] — Intrapartum prophylaxis [adequate / inadequate / not indicated] (Include antibiotic and timing if relevant.)
• Other perinatal exposures: [Relevant infection risks or exposures affecting newborn evaluation] (Omit if none.)

Hospital Course

(Problem-oriented summary. Include only problems that were present or evaluated. For each problem, briefly state the issue, evaluation, treatment, response, and discharge status. Focus on decisions and outcomes rather than day-by-day chronology. Omit this section format for uncomplicated well-newborn stays.)

[Problem]: [Issue/diagnosis]

[Concise assessment including pertinent findings, evaluations obtained, treatments provided, response, and current status.]

Discharge status: [resolved / improving / stable / requires follow-up] — [Specific actions or monitoring instructions if applicable.]

(Repeat problem subsections as needed for additional issues such as respiratory, cardiovascular, infectious risk/sepsis evaluation, glucose management, thermoregulation, feeding/hydration, procedures performed.)

Feeding Plan

Current feeding method: [direct breastfeeding / expressed breast milk / formula / combination]

Frequency and volume: [Feeding frequency and target volumes appropriate to method and age]

Latch/milk transfer: [adequate / concerns present / unknown]; Lactation support [involved / not involved] (If concerns, summarize issues and plan.)

Supplementation: [none / indication, method, volume targets, and taper plan]

Output last 24 hours: [number] voids, [number] stools (Note any concerns.)

Weight Trajectory

Birth weight: [g]

Lowest in-hospital weight: [g] (Include if nadir occurred.)

Discharge weight: [g] ([percent change] from birth)

Weight trend last 24 hours: [loss / stable / gain]

(If weight loss exceeds 7–10% or trajectory is concerning, explicitly link to feeding reassessment plan and bilirubin follow-up timing.)

Bilirubin Management

Bilirubin measurements:

• [Date/time], age [hours of life], [TcB / TSB] [value] mg/dL (Repeat for each measurement obtained.)

Risk factors: [prematurity / DAT positivity / bruising or cephalohematoma / suboptimal intake / G6PD risk / exclusive breastfeeding / none identified]

Phototherapy: [not indicated / given: start date/time, stop date/time, indication, rebound check result and timing] (Include only if phototherapy was administered.)

Bilirubin follow-up plan: Repeat bilirubin [needed / not needed]. If needed: [date/time window], [location], [ordering clinician], [who reviews results], [how family notified], [contingency if rising or near threshold]. (If no bilirubin was obtained during hospitalization, document rationale and outpatient follow-up plan.)

Newborn Screening & Prophylaxis

(Document actual status for each item. Do not infer completion or normal results.)

• Newborn metabolic screen: [done / pending / declined / not done], Date/time [date/time], Result [pending / normal / abnormal], Follow-up owner [responsible clinician]
• Hearing screening: [OAE / AABR], Left [pass / refer], Right [pass / refer], Date/time [date/time], Follow-up owner [responsible clinician] (If refer, document audiology referral and timeframe.)
• CCHD screening: Date/time [date/time], Age [hours of life], Pre-ductal SpO2 [%], Post-ductal SpO2 [%], Result [pass / fail], Follow-up owner [responsible clinician] (Should be performed at ≥24 hours of age.)
• Vitamin K: [given / declined], Dose/route [dose and route], Date/time [date/time] (If declined, document counseling provided and risk discussion.)
• Ophthalmic prophylaxis: [given / declined], Agent [agent name], Date/time [date/time] (If declined, document counseling provided.)
• Hepatitis B vaccine: Maternal HBsAg [positive / negative / unknown]; Vaccine [given / declined / deferred], Date/time [date/time]; HBIG [given / not indicated / indicated but not given with action plan]; Follow-up owner [responsible clinician] (Document shared decision-making discussion per current CDC guidance.)

Discharge Physical Examination

Last vitals: T [temp], HR [rate], RR [rate], SpO2 [%], BP [if obtained]

Growth: Weight [g], Length [cm], Head circumference [cm]

General: [Appearance, hydration, activity]

Skin: [Color, jaundice extent if present, bruising or cephalohematoma if present]

Cardiac: [Rate, rhythm, murmur present/absent, femoral pulses]

Lungs: [Work of breathing, breath sounds]

Abdomen: [Soft/distended, organomegaly, umbilical cord status]

Neuro: [Tone, alertness, primitive reflexes]

Hips: [Barlow/Ortolani findings, gluteal fold symmetry]

GU: [Genitalia, anus patent, voiding]

Circumcision site: [Appearance, hemostasis] (Include only if applicable.)

(Link abnormal findings to relevant follow-up items.)

Discharge Diagnoses

• [Primary: single liveborn infant, gestational age, mode of delivery]
• [Complications or resolved issues]
• [Active issues requiring follow-up]

(Order by clinical importance.)

Medications at Discharge

• [Medication, dose, route, frequency, indication]
• Vitamin D supplementation: [recommended / not indicated] (If recommended, include dose and instructions.)

(State "None" if no discharge medications.)

Follow-Up Plan

• Primary care: [Date/time], [Location], [Purpose] (Within 24–48 hours if early discharge, feeding/weight concerns, bilirubin near threshold, or abnormal screenings. If not yet scheduled, specify who will schedule and by when.)
• Weight check: [Date/time window], [Location], [Responsible clinician]
• Bilirubin recheck: [Date/time window], [Location], [Ordering clinician], [Who reviews], [Contingency if elevated] (Include only if repeat indicated.)
• Audiology: [Referral details, timeframe, responsible owner] (Include only if hearing screen referred.)
• Specialty referrals: [Service], [Reason], [Target timeframe], [Responsible owner] (Include only if applicable.)
• Other: [Lactation, home health, social work visits as applicable]

Pending Results

• [Test name]: Expected by [timeframe]; Reviewed by [responsible clinician]; Family notified via [method]; Contingency if abnormal [action plan]

(List each pending item with an assigned owner. State "None" if no pending results.)

Parent Education

• Safe sleep: Back to sleep, own sleep surface, no soft bedding, room-sharing without bed-sharing
• Feeding: Hunger cues, wake-to-feed guidance, expected frequency, when to seek help
• Jaundice: Warning signs, when and where to seek evaluation
• Fever/illness: Fever threshold ≥100.4°F (38°C), when to seek care, emergency signs
• Car seat safety: Rear-facing, proper installation
• Exposure avoidance: Smoke, vape, substance exposures, sick contacts
• Cord care: [Instructions provided] (Include if applicable.)
• Circumcision care: [Instructions provided] (Include if applicable.)
• Interpreter services: [Language, interpreter ID] (Include if used.)
• Written materials: [Provided / not provided], Language [language]
• Caregiver understanding: [Verbalized understanding / teach-back completed]