Abstract
Care of the newborn in an intensive care setting necessitates continuous monitoring and evaluation. Changing clinical status, laboratory data, fluid balance, nutritional information, and respiratory therapy are important parts of this care. Graphic representation of this data is essential for continual care and retrospective analysis. Each discipline involved in NICU care (nurse, respiratory therapist, laboratory assistant) have devised “forms” to assist them in caring for the sick neonate. The physician needs a simple form to record clinical notes and other information to prevent communication lapses and forgotten information.
We have designed a physician progress page which encompasses three separate problem-oriented records. The initial morning visit records present problems, current laboratory data, medications, pertinant physical findings, and the plan for the next few hours. A midday note on the back side of the page offers continual problem-oriented information with a therapy plan. The final note underneath the midday exam restates the problems, adds additional data, and organizes therapy. Interim visits, if necessary, are noted on regular progress notes. This method of physician problem-oriented progress notes eliminates forgotten or inaccurate information, organizes neonatal planning, and allows for a more complete summary at discharge.
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Martin, G., Ireland, W., Furman, G. et al. 673 PROBLEM-ORIENTED PHYSICIAN NEONATAL INTENSIVE CARE PROGRESS NOTES. Pediatr Res 15 (Suppl 4), 554 (1981). https://doi.org/10.1203/00006450-198104001-00696
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DOI: https://doi.org/10.1203/00006450-198104001-00696