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Newborn Discharge Summary Transcription Example / Sample

DATE OF ADMISSION:  MM/DD/YYYY

DATE OF DISCHARGE:  MM/DD/YYYY

DISCHARGE DIAGNOSIS:
The patient is (XX)-day-old now, a (XX) and 3/7 weeks, on ad lib feedings, ruled out sepsis.

MATERNAL HISTORY:
Mother is a (XX)-year-old gravida 1, para 0, with EDC of MM/DD/YYYY. She is AB positive, GBS negative, RPR negative, hepatitis surface antigen B negative, rubella immune.

Maternal prenatal medication administered was prenatal vitamins. No complications during pregnancy.

Rupture of membranes was spontaneous 25 hours prior to delivery with clear fluid noted. Mother did run a temperature during labor of 101.8 and there was a nonreassuring tracing, baby. The mother did receive ampicillin x4 doses, delivered vertex, vaginal vacuum assist. Nuchal cord x1, tight.

Apgars assigned to the baby were 8 at one minute and 9 at five minutes. Spontaneous respirations noted. Only required tactile stimulation and oxygen blow-by and the baby was taken to the newborn nursery. The baby's birth weight was 3265 grams, which was 7 pounds 2 ounces. The baby was transferred to the neonatal care service on day 1 of life with increased respiratory rate.

CBC screen was done and we are ruling out sepsis.

HOSPITAL COURSE:
1.  Initially, the baby had respiratory distress, increased respiratory rate, questionable transient tachypnea of the newborn. Blood gas was within normal limits. Her chest x-ray had some slight hyperinflation noted. Distress was resolved within 12 to 24 hours and no further problems noted.
2.  Possible sepsis, rule out. The baby was initially put on ampicillin and gentamicin. A CRP initially was done at less than 24 hours of age which was 0.4; a followup was 2.4. Maternal histories involve a maternal temperature during delivery of 101.8. Repeat CRP on day of discharge was 1.3. Antibiotics were discontinued and 48-hour blood cultures were negative with no further problems.
3.  Nutrition. The baby initially was placed n.p.o. and put on some IV fluids of D10W. Feedings were initiated on day 1 of life and advanced to an ad lib schedule. Currently, the baby is on ad lib feedings of Enfamil with iron and tolerating feeds with no problems. Stooling and voiding. Advancing weight appropriately.

DISCHARGE PHYSICAL EXAMINATION:
VITAL SIGNS:  Temperature 98.2, heart rate 142, respiratory rate 58 and blood pressure 86/56.
GENERAL:  The infant was alert and active. Discharge weight was 3280 grams.
HEENT:  Eyes x2, ears x2, symmetrical. Nares pink. Palate intact.
NECK:  Without masses. Left parietal cephalohematoma noted.
RESPIRATORY:  Symmetrical.
CHEST:  Bilateral breath sounds, clear and equal with good aeration.
CARDIOVASCULAR:  Regular rate and rhythm. No murmur noted. Pulses +2 x4. Capillary refill less than 2 seconds.
ABDOMEN:  Soft and nondistended. Bowel sounds positive.
GENITOURINARY:  Female genitalia. Anus patent.
SPINE:  Intact and straight.
EXTREMITIES:  Ten fingers/ten toes, hips negative for click, moves extremities well and symmetrically.
SKIN:  Pink, slightly icteric, intact, warm to the touch.

SCREENING:
Hearing screen done, passed both ears.

DISCHARGE INSTRUCTIONS:
Follow up with pediatrician after discharge.

Pediatric Discharge Summary Samples #1     Discharge Summary Sample Reports #2