NICU Discharge Summary

Header Block

Patient name: [Patient full name]

MRN: [Medical record number]

DOB: [Date of birth, YYYY-MM-DD]

Sex: [male / female / intersex / unknown]

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

Birth weight: [Birth weight in grams]

Birth length: [Birth length in centimeters]

Birth head circumference: [Birth head circumference in centimeters]

Plurality: [singleton / twin / triplet / higher-order]

Admission date/time: [Admission date and time, YYYY-MM-DD HH:MM]

Discharge date/time: [Discharge date and time, YYYY-MM-DD HH:MM]

Hospital name: [Hospital name]

Attending of record: [Attending clinician name and credentials]

Parent/guardian: [Name(s) and relationship(s)] (Include if relevant for care coordination)

Chronological age at discharge: [Calculated age in days]

Postmenstrual age at discharge: [PMA in weeks+days]

Corrected age at discharge: [Corrected age in weeks+days] (For preterm infants; if term, state "Not applicable")

Discharge Summary

• Primary reason for NICU admission: [Brief description]
• Top discharge diagnoses: [3–8 prioritized diagnoses] (Order by clinical priority)
• Status at discharge:
  • Respiratory: [room air / nasal cannula / HHFNC / CPAP / ventilator / trach-vent], [flow/FiO2 if applicable], [target SpO2 range]
  • Feeding: [PO / NG / GT / combination], [ad lib / scheduled], [tolerance summary]
  • Neurologic: [Baseline status, seizure control if applicable] (Include only if clinically relevant)
• Discharge anthropometrics: [Weight in grams], [Length in cm], [Head circumference in cm], [percentiles if available], [growth trend]
• Home feeding plan summary: [Feed type, caloric density, schedule, fortification]
• Home respiratory plan: [Oxygen flow/FiO2], [target SpO2], [weaning oversight by clinician/service] (Include only if applicable)
• Critical pending results: [Test name and responsible clinician] (If none, state "Pending results: none.")
• Key follow-up appointments: [PCP timing], [urgent specialty follow-ups with timeframe]
• Home equipment/services: [DME and home services list] (If none, state "Home equipment: none. Home services: none.")

Birth and Perinatal History

[Concise perinatal summary including: maternal conditions affecting newborn, pertinent prenatal labs influencing management, antenatal interventions if relevant, delivery mode and indication, Apgar scores, resuscitation summary, initial stabilization] (Include only clinically relevant details. If key prenatal labs are unavailable, document "Unknown in record" and note mitigation taken.)

Admission Diagnoses

Principal admitting diagnosis: [Diagnosis]

Secondary admitting diagnoses: [List of diagnoses present on admission]

[One-sentence rationale for NICU level care]

Hospital Course

(Organize by problems; include only relevant sections. Order by highest discharge risk first, then ongoing management burden, then resolved issues. For each problem: diagnosis/summary, key evaluations/findings, therapies/interventions, complications, status at discharge, and discharge plan/follow-up. Include dates only if they affect management.)

Respiratory

Diagnosis/summary: [RDS / BPD / CLD / apnea of prematurity / airway anomaly / other]

• Key evaluations/findings: [Relevant imaging, blood gases, oximetry studies]
• Therapies/interventions: [Ventilation modalities, surfactant, caffeine, diuretics, steroids, weaning milestones]
• Complications: [Complications if any]
• Status at discharge: [room air / NC at L/min / HHFNC / CPAP / trach-vent], [target SpO2 range]
• Discharge plan/follow-up: [Home oxygen settings], [weaning plan and overseeing clinician], [follow-up timing]

Cardiovascular

Diagnosis/summary: [PDA / PPHN / CHD / arrhythmia / other]

• Key evaluations/findings: [Echo conclusions, pertinent hemodynamics]
• Therapies/interventions: [Medical or surgical management, catheterization procedures]
• Status at discharge: [Hemodynamic stability, medications, monitoring needs]
• Discharge plan/follow-up: [Cardiology follow-up timing], [medication plan], [home monitoring if applicable]

Nutrition and Feeding

Diagnosis/summary: [NEC / feeding intolerance / GERD / TPN dependence / cholestasis / other]

• Key evaluations/findings: [Imaging, swallow study/FEES results, nutrition labs]
• Therapies/interventions: [TPN/lipids, feeding advancement, fortification, formula type, reflux management]
• Status at discharge: [PO / NG / GT], [ad lib / scheduled], [tolerance and aspiration precautions]
• Discharge plan/follow-up: [Diet specifics and volumes], [supplements], [outpatient RD/feeding therapy referrals]

Growth

Summary: [Weight, length, head circumference trajectories and concerns]

• Status at discharge: [Current anthropometrics with percentiles if available]
• Monitoring plan: [Weight check timing], [targets], [who will follow]

Infectious Disease

Diagnosis/summary: [Suspected or confirmed sepsis / bacteremia / meningitis / other]

• Key evaluations/findings: [Cultures, CSF, imaging, biomarkers with dates if decision-critical]
• Therapies/interventions: [Antimicrobials with start/stop dates and rationale]
• Status at discharge: [Completed or ongoing therapy, need for follow-up labs]
• Discharge plan/follow-up: [Follow-up labs], [ID follow-up timing], [monitoring plan]

Neurology and Development

Diagnosis/summary: [IVH / PVL / HIE / seizures / tone abnormalities / other]

• Key evaluations/findings: [Cranial ultrasound/MRI conclusions, EEG if applicable]
• Therapies/interventions: [Antiepileptics, neuroprotective measures, therapies]
• Status at discharge: [Neuro exam highlights, seizure control status]
• Discharge plan/follow-up: [Neurology follow-up], [early intervention referral status], [therapy services]

Hematology

Diagnosis/summary: [Anemia of prematurity / thrombocytopenia / other]

• Key evaluations/findings: [Pertinent labs and trends]
• Therapies/interventions: [Transfusions with dates, erythropoiesis support]
• Status at discharge: [Hgb/Hct/platelet status]
• Discharge plan/follow-up: [Iron supplementation], [monitoring labs and timing]

Endocrine and Metabolic

Diagnosis/summary: [Hypoglycemia / thyroid disorder / inborn error of metabolism / other]

• Key evaluations/findings: [Critical labs, endocrine consult conclusions]
• Therapies/interventions: [Glucose management, hormone replacement, dietary modifications]
• Status at discharge: [Control and stability]
• Discharge plan/follow-up: [Outpatient labs], [endocrine follow-up timing]

Renal

Diagnosis/summary: [AKI / hydronephrosis / electrolyte abnormalities / other]

• Key evaluations/findings: [Ultrasound results, creatinine and electrolytes]
• Therapies/interventions: [Fluid management, supplements]
• Status at discharge: [Current renal function and electrolyte status]
• Discharge plan/follow-up: [Monitoring labs], [nephrology follow-up]

Hepatic and Jaundice

Diagnosis/summary: [Hyperbilirubinemia / cholestasis / other]

• Key evaluations/findings: [Bilirubin trends, imaging if pertinent]
• Therapies/interventions: [Phototherapy, medications]
• Status at discharge: [Current bilirubin and liver function status]
• Discharge plan/follow-up: [Follow-up labs], [GI/hepatology follow-up]

Genetics and Congenital Anomalies

Diagnosis/summary: [Confirmed or suspected syndrome or anomaly]

• Key evaluations/findings: [Genetic testing sent with results or pending status]
• Counseling: [Genetic counseling provided: yes / no]
• Discharge plan/follow-up: [Pending test follow-up], [genetics clinic timing]

Surgery and Procedures

[Surgeries and procedures with indications, dates, and outcomes] (Defer operative specifics to op notes.)

Social and Care Coordination

[Discharge barriers, caregiver training completion, interpreter needs, custody or placement issues] (Include only items relevant to care coordination.)

Discharge Examination

Vital signs: [Temperature, HR, RR, BP, SpO2 with date/time] (If not available at discharge, state "Stable; last recorded [timestamp]")

Anthropometrics: [Weight in grams], [Length in cm], [Head circumference in cm], [percentiles if available]

Physical exam: [Systems-based exam emphasizing abnormal or clinically relevant findings: General, HEENT, Chest/Lungs, Cardiovascular, Abdomen, GU, Neuro, Skin, Extremities]

Active devices at discharge: [NG / GT / trach / oxygen / ostomy / VP shunt / other] (List all applicable; if none, state "None")

Diagnoses

Principal Discharge Diagnosis: [Diagnosis]

Secondary Diagnoses:

• [Diagnosis] — [ongoing / resolved] — follow-up required: [yes / no]

Procedures

• [Procedure name] — [Date, YYYY-MM-DD] — [Laterality if applicable] — [Brief indication] — [Surgeon/service if major] — [Outcome]

(If none, state "None.")

Medications at Discharge

• [Medication name (generic)]: [Formulation/strength], [Dose with mg/kg/day if helpful], [Route], [Frequency], [Indication], [Start date], [Planned stop date if applicable], [Special instructions] — [Continue / New / Changed / Stop]

Reconciliation: [Medications reviewed with caregivers: yes / no], [Date], [Caregiver name]

(If no discharge medications, state "None.")

Allergies

• [Drug/substance]: [Reaction type]

(If none, state "No known drug allergies (NKDA).")

Home Feeding Plan

• Route: [PO / NG / GT / combination]
• What to feed: [Human milk (maternal/donor) / formula type], [fortifier if used]
• Caloric density and recipe: [kcal/oz], [explicit mixing instructions]
• Schedule: [ad lib with minimum volumes / set volumes and frequency], [overnight plan], [maximum interval between feeds]
• Feeding equipment: [Nipple type/flow], [pump settings for tube feeds: rate, volume, duration]
• Supplements: [Vitamin D dose/frequency], [Iron dose/frequency], [Sodium], [Phosphate], [MCT oil], [Other]
• Feeding safety precautions: [Aspiration precautions], [positioning], [pacing], [signs to stop feeding]
• Growth monitoring plan: [Weight check timing], [who reviews growth], [dietitian involvement]

Home Equipment and Services

• DME: [Oxygen with flow/FiO2 and target SpO2], [pulse oximeter with alarm parameters], [apnea monitor], [suction], [nebulizer], [feeding pump], [GT supplies], [ostomy supplies], [other]
• Home services: [Home nursing], [early intervention], [WIC], [lactation support], [social work], [other]
• Caregiver training completed: [CPR], [oxygen safety], [trach care], [tube feeding], [medication administration], [device troubleshooting]

(If none needed, state "Home equipment: none. Home services: none.")

Screening and Preventive Care

• Newborn Metabolic Screen: [Completed / Not completed / Pending / Not indicated], [date(s) sent], [results or pending status], [repeat plan if needed]
• Hearing Screen: [Pass / Refer], [method: AABR / OAE], [date], [audiology follow-up plan if refer or risk factors]
• CCHD Screen: [Pass / Fail / Not applicable], [reason if not applicable], [date], [follow-up plan]
• ROP Screening: [Last exam findings], [date], [next exam date/time/location], [responsible clinician]
• Car Seat Evaluation: [Pass / Fail], [duration observed], [car bed required: yes / no]
• Immunizations: [Vaccines given with dates], [outstanding vaccines and plan]
• RSV Prevention: [Maternal RSV vaccine status if known], [infant monoclonal product, date, dose], [follow-up plan if not yet given]

(If results are missing, document "Unknown in record" and note mitigation plan.)

Pending Results

• [Test name] — [Date sent, YYYY-MM-DD] — [Expected turnaround] — [Responsible clinician] — [Action plan]

(If none, state "None.")

Discharge Disposition

Disposition: [home / foster care / transfer / hospice / other]

Condition at Discharge: [stable / improved / unchanged] — [brief specifics]

Transportation: [Private vehicle / ambulance], [car seat / car bed], [oxygen in transit if applicable]

Follow-up Appointments

• Primary care/medical home: [Clinician], [reason], [date/time or timeframe], [contact info], [status: scheduled / referral placed / family to schedule]
• Ophthalmology/ROP: [Clinician], [reason], [date/time], [contact info], [status]
• Audiology: [Clinician], [reason], [date/time], [contact info], [status]
• Cardiology: [Clinician], [reason], [date/time], [contact info], [status]
• Pulmonology: [Clinician], [reason], [date/time], [contact info], [status]
• Other specialties: [Service], [reason], [date/time], [contact info], [status]
• High-risk infant follow-up clinic: [Clinic name], [date/time or timeframe], [contact info], [status]
• Early intervention referral: [Submitted: yes / no], [agency/contact], [status and timeframe]
• Home health visits: [Agency], [frequency], [start date]

(If a clinically required follow-up is not scheduled, document the gap and who is responsible for scheduling.)

Caregiver Education and Return Precautions

Education completed: [Topics covered and competencies demonstrated]

Return precautions: [Signs of respiratory distress], [feeding intolerance or aspiration signs], [fever threshold], [dehydration signs], [other condition-specific risks]

Safety counseling: [Safe sleep], [smoke exposure avoidance], [car seat safety]

Communication

PCP notified of discharge: [yes / no], [method: phone / fax / EHR], [date/time]

Discharge summary transmitted: [Method], [date/time]

NICU contact for follow-up questions: [Name/role], [phone], [email]

Signature

Discharging clinician: [Name, credentials]

Signature: [Electronic or handwritten signature] — [Date/time, YYYY-MM-DD HH:MM]

(If unsigned at generation, mark "Pending signature.")