NICU Significant Event Note (Acute Change)

Date/Time of Event: [date and 24-hour time of event] (Use "~" for approximate times; label as "Late entry" if written after the event.)

Date/Time of Note: [date and 24-hour time written]

Author: [name / role / credentials]

Patient: [name / MRN / location]

GA at Birth / PMA / DOL: [gestational age at birth / postmenstrual age / day of life]

Current Weight: [weight with units]

Event Summary

[1–3 sentence summary: At (time), infant developed (event). (Key interventions). Currently (status on current support).] (Maintain factual, time-anchored language; avoid speculation or blame.)

Background

[Pre-event baseline relevant to interpreting this event: respiratory support/settings, hemodynamic status, feeding status, recent procedures/medications/handling changes, and other pertinent active diagnoses] (Omit elements not pertinent to this specific event.)

Timeline

• [HH:MM] [Initial recognition: observation/finding] (Attribute source if applicable, e.g., "per RN report.")
• [HH:MM] [Action taken] → [Response]
• [HH:MM] [Escalation/intervention] → [Response]
• [HH:MM] [Diagnostics obtained]
• [HH:MM] [Further interventions] → [Response]
• [HH:MM] [Stabilization achieved / ongoing instability with current status]

(Use 24-hour time; mark approximate times with "~". Include only key inflection points. Reference separate procedure notes rather than duplicating procedural details.)

Assessment

Focused Exam: [Pertinent positives and negatives targeted to the event—general appearance, respiratory, cardiovascular/perfusion, and other systems as relevant]

Data: [Vital sign trends around the event; respiratory support before/after with mode, settings, FiO2; blood gas with time and type; other pertinent labs; imaging findings with preliminary vs final status] (Use compact before/after comparisons.)

Working Diagnosis: [Leading concern and brief differential if uncertainty remains]

Plan

(Problem-oriented, ordered by acuity. Include only problems affected by or relevant to this event.)

• [Problem 1]: [Current status. Immediate plan. Monitoring parameters with explicit escalation thresholds. Follow-up timing for repeat labs/imaging/reassessment.]
• [Problem 2]: [Current status. Immediate plan. Monitoring and escalation thresholds. Follow-up.]
• [Additional problems as needed]

(Reference separate procedure notes rather than duplicating details.)

Communication

• Team notifications: [Who notified (attending / fellow / consults), time(s), resulting decisions]
• Family/guardian: [Time, with whom, summary of discussion, questions/decisions]
• Critical results: [Result, who reported/received, action taken]

(Omit if no communications beyond routine team awareness.)

(If information could not be obtained due to emergent stabilization, state explicitly. Do not reference incident reports or internal quality review processes.)