Neonatal Progress Note (Phill)

VCOFH [patient's name] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely) Day: [age in days] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely) GA: [gestational age] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely) cGA: [corrected gestational age] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely) Birth weight: [birth weight] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely) Current weight: [today's weight, including change from last measurement] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely) ISSUES - [provide a brief summary of the patient's current condition, including diagnosis, relevant history, and reason for ICU admission] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely) MEDICATIONS - [list all medications that the patient is prescribed, including comments on last doses if mentioned in transcript] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely) PROGRESS - [comment on any changes to the patient's status since the last review] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely) ASSESSMENT AND EXAMINATION A (bold) - [describe airway status, any interventions, clinical examination findings and current management] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely) B (bold) - [describe respiratory status, ventilator settings, oxygen requirements, clinical examination findings and any interventions] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely) C (bold) - [describe cardiovascular status, blood pressure, heart rate, medications, clinical examination findings and any interventions] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely) D (bold) - [describe neurological status, Glasgow Coma Scale (GCS) score, sedation, clinical examination findings and any interventions] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely) E (bold) - [describe skin condition, wounds, and any interventions] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [include lab results of electrolytes] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely) FEEDS / FLUIDS TFI [total fluid intake, also known as TFI] mL/kg/day - [note how the baby is feeding, e.g. breast feeding, bottle feeding, nasogastric tube feeding. note whether the baby is drinking breast milk, which may also be called EBM. if the baby is not drinking breast milk, write down formula and the name of the formula] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely) - [comment on how the baby is tolerating feeds] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely) - [if the baby is on intravenous fluids, note what type of fluid they are having and the location and condition of their cannula] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely) - [comment on frequency of wet and / or dirty nappies] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely) - [comment on glycaemic control and recent blood sugar readings] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely) H (bold) - [describe hematological status, lab results, blood gas results, transfusions, and any interventions] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely) I (bold) - [describe signs of infection, temperature, cultures, antibiotics, and any interventions] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely) SOCIAL - [comment on whether the patient's family are present, if they have any questions and if any concerns have been raised by them or the nursing staff. include quotes if relevant in discussion] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely) PLAN - [Describe management plan in a list format] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely) (Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or section blank.)