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Discipline

: Paediatrics

Sub Discipline

: Neonatology

Document Title

: Neonatal Discharge Summary

Unit

Header / Title

Address

Place Of Birth

Date Of Admission

Date Of Discharge

Date And Time Of Death

Length Of Stay (Los)

Final Diagnosis

Lethal Congenital Anomalies

YesNo

MATERNAL HISTORY

Mother's Age

Gravida

Para

Abortion

Living Children

Vdrl +

Hiv +

Others

ANTENATAL PROBLEMS

Gestational Age

By LMP

Weeks Days

By Ultrasound

Weeks Days

Maternal Diabetes (Including Gestational Diabetes)

YesNoUnknown

Comments

Maternal Hypertension, Chronic Pregnancy Included

YesNoUnknown

Comments

Maternal Eclampsia

YesNoUnknown

Comments

Maternal Chorioamnionitis

YesNoUnknown

Comments

Maternal Anaemia

YesNoUnknown

Comments

Maternal Abruption Placenta

YesNoUnknown

Comments

Maternal Bleeding Placenta Praevia

YesNoUnknown

Comments

Antenatal Steroid

YesNoUnknown

Comments

Intrapartum Antibiotic

YesNoUnknown

Comments

LABOUR AND DELIVERY

Labour

Rupture Of Membranes

SROM

ARM

PROM

PPROM

Liquor

Clear

Bloody

Meconium

Foul smelling

Oligohydramnions

Fetal Distress

None

Meconium stained liquor

Comments

Cord Prolapse

Comments

CTG

Cord pH Arterial

Common Numeric

Cord pH Venous

Common Numeric

Final Mode Of Delivery

Mode

Assistance

Cord Prolapse

Sex

Multiplicity

Apgar Scores

Please Update Method

Resuscitation And Stabilization

At Birth

Growth Status

POSTNATAL COURSE

Major Congenital Anomaly

YesNo

Syndrome

Isolated Major Anomaly

Hydrops Fetalis

Skeletal Dysplasia

Respiratory

Normal

YesNo

TTN

RDS

Congentital Pneumonia

MAS

Congenital anomaly

Others, specify

Surfactant

YesNo

Conventional

Hfov / Hfjv

Cpap / Bilevel Cpap

Others

Oxygen Therapy

Nitric Oxide

Complications

Pneumothorax

PIE

Ventilator Associated Pneumonia

Others, specify

Bronchopulmonary Dysplasia

YesNo

Steroids

Stop Oxygen At Weeks Of CGA

Apnea Of Prematurity

YesNo

Theophylline

Caffeine

Others, specify

Cardiovascular System

Normal

YesNo

Congenital Cyanotic Heart Disease

Congenital Acyanotic Heart Disease

Rhythm abnormality

PDA

Ibuprofen

Indomethacin

Ligation

Others, specify

Heart Failure

YesNo

Other Cardiac Condition

Echo

YesNo

Pphn

YesNo

Nitric Oxide

HFOV

Magnesium Sulphate

Slidenafil

Others, specify

Nnj

YesNo

Cause

Gastrointestinal Tract

Normal

YesNo

NEC

Congenital anomaly

Other GIT Condition

Central Nervous System

Normal

YesNo

HIE

IVH

Treatment

VP shunt

Reservoir insertion

External ventricular drainage

PVL

Specify

Meningitis

Confirm by Lumbar Puncture (LP)

YesNo

Specify Organism

Ventriculitis

Neonatal Seizures

YesNo

Treatment

Congenital anomaly

YesNo

Genitourinary Tract

Normal

YesNo

Congenital anomaly

UTI

Specify Organism

Others, specify

Metabolic

Normal

YesNo

Inborn Error Of Metabolism

Haematology

Normal

YesNo

Anemia of prematurity

Hb At Discharge (G/Di)

Thrombocytopenia

Specify Cause

Others

Osteopenia Of Prematurity

Normal

YesNo

Alp

Endocrine

Normal

YesNo

Congenital Hypothyroidism

Treatment

Symptomatic Hypoglycaemia

Treatment

Others

Infection

YesNo

Septicaemia

Early onset (<= 72 hours of life)

Organism

Group B Streptococcus

Fungal

Later onset (>= 72 hours of life)

Organism

Fungal

Hospital acquired

Organism

Group B Streptococcus

Fungal

Others

CLABSI

Others, specify

Eye

Normal

YesNo

Rop Screening Done ?

Not applicableNoYes

Other Problems/Diagnosis

Nutrition

Parenteral Nutrition

Duration Of Tpn

Enteral Nutrition At Discharge

Breastfeeding

Special Formula

Tube feeding

Neonatal Screening

Cord Blood Tsh

Cord Blood Free T4

G6pd Status

Universal Newborn Hearing Screening

Please Update Method

Pulse Oxymetry (%)

Others

Immunization

Medications At Discharge

Discharge At

Weeks CGA

Current Weight (KG)

Current Length (Cm)

Current Coh (Cm)

Discharge To

Remaining Active Problems / Care Plan

Follow-up / appointments

Paediatrics Clinic

Review in Daycare

Other Clinics in Hospital

Other Health Facility

Transfer Out to Other Hospital

Hospital Name

Comments

Plan

SIGNATURES

Notes Component

MATERNAL HISTORY
ANTENATAL PROBLEMS
LABOUR AND DELIVERY
POSTNATAL COURSE
SIGNATURES

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