Paediatrician Template

Neonatal Progress Note (Phill)

A professional Paediatrician template for healthcare professionals.

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Specialty

Paediatrician

Used

20 times

Type

Note

Last edited

2026/01/31

Created by

Phillip Maude

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About this template

Need a clear and concise way to document your neonatal patient's progress? This Neonatal Progress Note template is designed for paediatricians and neonatologists to efficiently record vital information. It covers everything from airway and respiratory status to feeds and social considerations. This template helps you create comprehensive notes, ensuring all critical aspects of the baby's care are documented. With Heidi, this template can be quickly populated from your visit transcript, saving you time and improving the accuracy of your medical documentation.

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VCOFH Baby Smith Day: 7 GA: 38 weeks cGA: 37 weeks Birth weight: 2.8 kg Current weight: 2.7 kg (down 100g since yesterday) ISSUES - Admitted to NICU for respiratory distress syndrome (RDS) and prematurity. Currently stable on CPAP. MEDICATIONS - Caffeine citrate 20mg IV q12h (last dose 08:00) - Curosurf 200mg via ETT (given at birth) - Paracetamol 60mg PRN for pain (last dose not given) PROGRESS - Baby Smith is showing improvement in respiratory effort and oxygen requirements. Tolerating feeds well. ASSESSMENT AND EXAMINATION A - Airway patent, on CPAP at 5cm H2O, FiO2 30%. Chest auscultation reveals equal air entry bilaterally. No retractions. B - Respiratory rate 45 breaths/min. CPAP at 5cm H2O, FiO2 30%. Oxygen saturations consistently above 90%. C - Heart rate 140 bpm, blood pressure 55/30 mmHg. Capillary refill time < 3 seconds. No murmurs auscultated. Maintaining blood pressure with fluids. D - Responding to stimuli appropriately. Moving all limbs. GCS 15. No seizures observed. E - Skin intact. No rashes or lesions. Electrolytes within normal limits. FEEDS / FLUIDS TFI 150 mL/kg/day - Currently receiving EBM via orogastric tube at 2ml every 3 hours. - Tolerating feeds well, with minimal residual. - IV fluids: D10W at 60ml/hr via peripheral cannula in right hand, cannula site clean and dry. - Wet nappies 6 per day, dirty nappies 2 per day. - Blood sugar readings stable, between 4.5-6.0 mmol/L. H - Hb 150 g/L, WCC 12 x 10^9/L, Platelets 250 x 10^9/L. No transfusions required. I - Temperature 37.2°C. Blood cultures negative. Started on IV amoxicillin and gentamicin for suspected sepsis. SOCIAL - Parents present and at bedside. They are concerned about the baby's breathing but are reassured by the improvement. They are asking about when they can hold the baby. PLAN - Continue CPAP and monitor respiratory status. - Continue feeds as tolerated. - Review antibiotics in 48 hours. - Monitor blood sugars. - Discuss with parents about holding the baby. - Review daily.