NICU Admission Note (Neonatology H&P)

Date/Time of Note: [Date and time of documentation]

Date/Time of NICU Admission: [Date and time of NICU admission]

Infant Name/MRN: [System-generated identifier]

Source of History: [maternal prenatal record / delivery record / transfer documents / caregiver interview] (List all sources used; specify limitations such as "outside hospital prenatal labs pending" or "maternal history unavailable." If records are missing, enumerate specific records requested.)

One-Line Summary: [Single sentence capturing infant sex, gestational age with dating method, birthweight, delivery mode with indication, and primary reason for NICU admission] (Do not infer details not explicitly documented.)

Chief Concern / Indication for Admission

[Primary admission indication and immediate clinical stability] (Limit to 1–3 sentences. State acuity, support needs, and immediate concerns.)

Maternal / Prenatal / Antepartum History

• Maternal demographics: [Maternal age], [Gravida/Para], [Prenatal care: established / late / none], [Relevant prior pregnancy outcomes]
• Maternal medical conditions: [Diabetes type and control], [Hypertensive disorder], [Thyroid disease], [Autoimmune conditions], [Other conditions impacting neonatal care] (Specify if on treatment.)
• Substance exposures: [tobacco / alcohol / opioids / stimulants / cannabis / none / unknown] (Include timing and frequency if documented.)
• Medications during pregnancy: [Antenatal steroids with agent, doses, timing], [Magnesium sulfate], [SSRIs], [Antiepileptics], [Other relevant medications]
• Infectious exposures: [HSV], [HIV], [HBsAg], [Syphilis], [Chorioamnionitis: suspected / confirmed], [Other] (Include dates and treatments if known.)
• Multiple gestation: [Singleton / Multiple with chorionicity/amnionicity if known]
• Prenatal labs: ABO/Rh [result], Antibody screen [result], GBS [result / date / method], HIV [result], HBsAg [result], Syphilis serology [result], Rubella immunity [result], GC/CT [result] (Record "unknown" or "pending" for undocumented results rather than omitting.)
• Prenatal ultrasound findings: [Growth status], [Doppler findings], [Anomalies], [Amniotic fluid], [Placental findings]
• Pregnancy complications: [PPROM/ROM date and duration], [Oligohydramnios / Polyhydramnios], [IUGR with Doppler findings], [Maternal antibiotics with agent and timing relative to delivery], [Other complications]
• Record availability: [Maternal history available / unavailable] (If unavailable, list specific records requested.)

Intrapartum & Delivery

• Labor: [Spontaneous / Induced with indication], [Fetal monitoring concerns if relevant to delivery decision]
• ROM: [SROM / AROM], [Date/time], [Duration], [Amniotic fluid character]
• Maternal intrapartum course: [Fever: yes / no], [Suspected intraamniotic infection: yes / no], [Intrapartum antibiotics with agent and timing]
• Delivery: [Mode], [Presentation], [Indication], [Delayed cord clamping / cord milking: performed / not performed], [Cord gases with UA/UV values if available], [Placenta disposition]
• Apgar scores: 1 min [score], 5 min [score], [Additional scores at 10/15/20 min if resuscitation ongoing] (Note if scores assigned during active resuscitation.)

Delivery Room / Immediate Postnatal Course

(Provide a time-anchored account of resuscitation and stabilization. Use "intervention → response" format. If not present at delivery, begin with "Per delivery record" and document only what is explicitly recorded.)

• Initial condition at birth: [Tone, respiratory effort, heart rate]
• Resuscitation sequence: [Time-stamped interventions with responses: warming/drying/stimulation, CPAP, PPV, intubation with ETT size/depth, chest compressions, medications with doses, surfactant, line placement, glucose management, thermoregulation measures]
• Transport to NICU: [Method and respiratory support during transfer]

NICU Admission Status

• Vital Signs: T [value], HR [value], RR [value], BP [value], SpO₂ [value]
• Thermoregulation: [Radiant warmer / Isolette / Other]
• Respiratory Support: [Type and settings including FiO₂, CPAP/PEEP level, ventilator mode/pressures/rate as applicable]
• Lines/Access: [PIV / UVC / UAC / ETT / OG / NG] (Include size, depth, and confirmation status for each.)
• Initial Studies: [Labs obtained with key abnormalities], [Imaging with status] (Include only clinically meaningful results; do not paste full lab reports.)

Focused Neonatal History

(Include for outborn infants or those transferred from newborn nursery; omit section if not applicable.)

• Feeding/Elimination: [Feeds attempted], [Tolerance], [Emesis], [Voids], [Stools], [Hypoglycemia screens and treatments]
• Prophylaxis: Vitamin K [given with time / deferred with reason], Eye prophylaxis [given / deferred], Hepatitis B vaccine [given / deferred with reason and follow-up plan], HBIG [given / not indicated]

Past History / Medications / Allergies

• Past medical/surgical history: [None (newborn) / Outborn course summary]
• Medications at admission: [Antibiotics, IV fluids, respiratory medications, pressors, sedation/analgesia with doses and rates] (Use unambiguous units; avoid error-prone abbreviations.)
• Allergies: [NKDA / Allergy with reaction type]

Physical Examination

Anthropometrics: Birthweight [value g], Current weight [value g], Length [value cm], Head circumference [value cm]

Vital Signs: T [value], HR [value], RR [value], BP [value], SpO₂ [value]

(Note exam limitations if applicable, e.g., "limited due to intubation/sedation.")

• General: [Appearance, tone, activity, distress level]
• Head/Neck: [Fontanelles, molding, cephalohematoma, palate, neck]
• Eyes/Ears: [Red reflex if assessed, external ear findings]
• Chest/Lungs: [Work of breathing, retractions, breath sounds, air entry symmetry]
• Cardiovascular: [Rate/rhythm, murmurs, pulses, perfusion, capillary refill]
• Abdomen: [Contour, organomegaly, bowel sounds, umbilicus]
• Genitourinary: [Sex characteristics, testes position if male, anal patency]
• Skin: [Color, jaundice, rashes, bruising, integrity]
• Musculoskeletal: [Clavicles, hips, limb movement]
• Neurologic: [Tone, primitive reflexes, responsiveness] (Note sedation effects if applicable.)
• Back/Spine: [Sacral dimple, defects]
• Dysmorphology: [Objective description if present; note genetics consult if indicated]

Data Reviewed

• Infant studies: [Blood gas], [Point-of-care glucose], [CBC], [Blood culture status], [CXR/Imaging] (Include date/time; mark pending studies as such.)
• Maternal labs reviewed: [GBS, HIV, HBsAg, Syphilis with source and dates]

Assessment and Plan

(Use problem-based format ordered by acuity: life-threatening instability first, then infectious/metabolic risks, nutrition/supportive care, and screening/follow-up. For each problem, state the diagnosis or clinical impression with supporting data, current trajectory, differential if unconfirmed, and specific plan with monitoring parameters. Label clinical impressions clearly, e.g., "likely TTN vs RDS." Do not infer undocumented history.)

[Problem]: [Diagnosis or clinical impression]

[Brief assessment with key supporting data and current status: improving / stable / worsening / uncertain]

• Plan: [Diagnostics, therapies with doses/rates, monitoring parameters, escalation/de-escalation criteria, reassessment timing]

(Include additional problems as clinically indicated. Common categories: Respiratory, Cardiovascular, Infectious Disease/Sepsis Evaluation, Fluids/Electrolytes/Glucose, Nutrition/TPN, Hematology/Jaundice, Neurology/Developmental Care, Lines/Access, Consults. For sepsis evaluation, explicitly document maternal risk factors, tests obtained, antibiotic agent and start time, and reassessment/stop criteria at 36–48 hours.)

Family Communication

• Contacts: [Parents/guardians updated], [Date/time], [By whom]
• Discussion: [Diagnosis, risks, planned interventions, anticipated course, family questions and understanding]
• Interpreter: [Language and method if used]
• Consents: [Lines / Transfusion / Donor milk / Procedures: obtained / pending]

Pending Items / Follow-Up Tasks

• [Records to obtain]
• [Pending studies with expected review time]
• [Planned reassessment timepoints]