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Neonatal Discharge Summary

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Unit

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Header / Title

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Address

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Place Of Birth

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Date Of Admission

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Date Of Discharge

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Date And Time Of Death

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Length Of Stay (Los)

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Final Diagnosis

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Lethal Congenital Anomalies

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MATERNAL HISTORY

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Mother's Age

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Gravida

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Para

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Abortion

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Living Children

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Vdrl +

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Hiv +

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Others

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ANTENATAL PROBLEMS

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Gestational Age

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By LMP

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By Ultrasound

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Maternal Diabetes (Including Gestational Diabetes)

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Maternal Hypertension, Chronic Pregnancy Included

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Maternal Eclampsia

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Maternal Chorioamnionitis

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Maternal Anaemia

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Maternal Abruption Placenta

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Maternal Bleeding Placenta Praevia

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Antenatal Steroid

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Intrapartum Antibiotic

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LABOUR AND DELIVERY

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Labour

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Rupture Of Membranes

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Liquor

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Fetal Distress

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Final Mode Of Delivery

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Mode

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Assistance

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Cord Prolapse

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Sex

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Multiplicity

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Apgar Scores

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Resuscitation And Stabilization

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At Birth

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Growth Status

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POSTNATAL COURSE

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Major Congenital Anomaly

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Respiratory

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Normal

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Surfactant

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Conventional

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Hfov / Hfjv

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Cpap / Bilevel Cpap

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Others

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Oxygen Therapy

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Nitric Oxide

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Complications

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Bronchopulmonary Dysplasia

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Stop Oxygen At Weeks Of CGA

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Apnea Of Prematurity

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Cardiovascular System

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Normal

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Heart Failure

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Other Cardiac Condition

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Echo

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Pphn

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Nnj

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Gastrointestinal Tract

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Normal

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Central Nervous System

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Normal

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Genitourinary Tract

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Normal

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Metabolic

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Normal

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Haematology

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Normal

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Osteopenia Of Prematurity

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Normal

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Endocrine

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Normal

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Infection

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Eye

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Normal

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Rop Screening Done ?

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Other Problems/Diagnosis

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Nutrition

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Parenteral Nutrition

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Duration Of Tpn

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Enteral Nutrition At Discharge

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Neonatal Screening

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Cord Blood Tsh

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Cord Blood Free T4

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G6pd Status

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Universal Newborn Hearing Screening

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Pulse Oxymetry (%)

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Others

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Immunization

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Medications At Discharge

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Discharge At

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Weeks CGA

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Current Weight (KG)

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Current Length (Cm)

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Current Coh (Cm)

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Discharge To

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Remaining Active Problems / Care Plan

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Follow-up / appointments

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Comments

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Plan

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SIGNATURES

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MATERNAL HISTORY
ANTENATAL PROBLEMS
LABOUR AND DELIVERY
POSTNATAL COURSE
SIGNATURES