NICU Daily Progress Note (Systems-Based)

Patient: [infant name or Baby Girl/Boy Last Name], [MRN], [location]

DOL/Age: Day of life [#], PMA [wk+d], ex-[GA at birth]

Weight: [current kg] ([+/- g] from yesterday)

Primary diagnoses: [key active problems]

24-Hour Summary

[Overnight course and interval events in one to two sentences] (Include only meaningful events: respiratory changes, A/B/D episodes requiring intervention, feeding intolerance, hemodynamic instability, cultures obtained, procedures, or significant family discussions. If no acute events, state "No acute events overnight.")

Objective

• Vitals: [Temp, HR, RR, BP/MAP, SpO2 ranges as relevant]
• I/O and Nutrition:
  • Total fluids: [mL/kg/day]
  • Enteral: [type, fortification, route, volume/frequency]
  • TPN: [GIR, protein, lipids] (if applicable; omit if not on TPN)
  • UOP: [mL/kg/hr]; Stool: [pattern]
• Respiratory: [Current support/settings, FiO2]; A/B/D: [count or "none"]; Gas: [key values if relevant to today's decisions]
• Exam: [Pertinent positives and negatives—tone, respiratory effort, perfusion, abdomen, skin, line sites as applicable] (Do not list systems not examined)
• Lines/Access: [Each device with type, site, day #, indication] (If no central lines, state "No central lines")
• Labs/Data: [Key values with timing relevant to today's decisions; culture status] (Use "pending" for unreturned results)

Assessment & Plan by System

(Include only systems with active issues or ongoing management. Begin each with brief assessment, then concrete 24-hour plan with specific thresholds. For safety-critical items—lines, antibiotics, respiratory support, A/B/D—use explicit "none" statements rather than omission.)

FEN/GI: [Assessment of feeding tolerance, growth, fluid/electrolyte status]

• [Enteral plan: advance/hold/fortify with target and criteria]
• [TPN/IVF plan if applicable]
• [Electrolyte/supplement adjustments and monitoring schedule]

Resp: [Assessment of respiratory stability and trend]

• [Support plan with weaning/escalation criteria and specific thresholds]
• [Caffeine plan if applicable]
• [Gas/imaging only if clinically indicated]

CV: [Assessment of perfusion and hemodynamics]

• [Vasoactive/fluid strategy if applicable with titration goals]
• [PDA/echo follow-up only if affecting management]

ID: [Assessment of infection risk/status]

• Antibiotics: [none / agent, indication, day #/planned duration, stop date]
• [Culture status and de-escalation plan]

Neuro/Pain: [Assessment of neuro exam and comfort]

• [Sedation/analgesia plan if applicable]
• [Imaging follow-up schedule if indicated]
• [Developmental care strategies]

Heme/Bili: [Assessment of anemia/jaundice status]

• [Transfusion thresholds with clinical context]
• [Phototherapy criteria and next bilirubin timing]

Renal/Metabolic: [Assessment of renal function, electrolytes, glucose]

• [Electrolyte replacement strategy and monitoring schedule]
• [Fluid balance goals; diuretic plan if applicable]

Lines/Access: [Daily necessity review—required for CLABSI prevention]

• [Each device: still indicated because (rationale); plan to continue/remove by (timeframe)]
• (If no central lines, state "No central lines")

Social/Dispo: [Family communication and discharge planning]

• [Who updated, by whom, key topics]
• [Discharge milestones: feeding, weight, apnea-free, temp stability, parent teaching]
• [Pending follow-up arrangements]

Health Maintenance: [Preventive care status—required documentation]

• ROP: [status], next due: [date / not yet eligible]
• Newborn screen: [sent / result / pending]
• Immunizations: [due / completed / not yet eligible]
• Hearing screen: [completed / pending / not yet eligible]

(For stable feeder-growers, condense to FEN/GI, Lines/Access, Social/Dispo, and Health Maintenance. Omit inactive systems.)