Over 500 Medical Transcription Sample Reports For Medical Transcriptionists!!

Infant Discharge Summary Transcription Template / Sample Report

HISTORY OF PRESENT ILLNESS:  This baby boy was delivered by C-section to a (XX)-year-old gravida 1, para 0 mother at 33 and 2/7 weeks' gestation.  Prenatal history was significant for placenta previa with active bleeding that led to the C-section.  Apgar scores were 7 at one minute, 8 at five minutes.  At the time of delivery, the infant received blow-by oxygen, suctioning, stimulation.

PHYSICAL FINDINGS ON ADMISSION:  Twin B male AGA newborn infant.  Birth weight 2060 grams.  Birth length 46 cm.  Head circumference 32 cm.  Vital Signs:  Temperature 98.4.  Heart rate 160.  Respiratory rate 36.  Blood pressure 54/36.  Admission Chemstrip of 33.  On room air, pulse oximetry greater than 90%.  Skin:  Good capillary refill.  No rashes and no bruises.  HEENT:  Anterior fontanelle open and flat.  Eye exam deferred.  Palate intact.  Lungs:  Good air entry bilaterally.  Cardiovascular:  Regular rate and rhythm, no murmur.  Abdomen:  Soft, no masses.  Extremities:  Moving all.  Hips stable.  Genitalia:  Grossly normal male, testes palpable.  Neurologic:  Fair tone.  Anus:  Patent.

FEEDINGS:  Ad lib NeoSure.

1.  Premature appropriate for gestational age male newborn infant.
2.  Twin B.
3.  Observed for sepsis.

INITIAL TREATMENT:  NICU admission, CBC and blood culture. NPO and IV fluids for hypoglycemia protocol.

1.  Hypoglycemia:  The infant had admission Chemstrip of 33 mg/dL, responded very well to the initiation of intravenous fluid with D10 water.
2.  Infectious:  Antibiotics were given.  CBC was benign.  Blood culture was negative.
3.  Thrombocytopenia:  Admission platelet count was 87,000 and subsequent CBC revealed the platelet count to be 102,000.  CBC done prior to discharge and those results are pending.
4.  Nutrition:  The infant required IV fluids for first 3 days of life.  Enteral feeding was begun on day 1 of life, was full enteral feeding by day 3-4 or 5.  The infant did require partial gavage feedings until day 14 of life.  Presently, the infant is tolerating NeoSure ad lib on demand very well.

DISCHARGE PHYSICAL EXAMINATION:  Weight on discharge 2146 grams, length 46.5 cm and head circumference 33 cm.  The baby is an active, alert, well appearing preterm male newborn infant.  HEENT:  Eyes:  Positive red reflex, both eyes.  Neck:  Supple.  Lungs:  Clear breath sounds.  Heart:  Regular rate and rhythm, no murmur.  Abdomen:  Soft and positive bowel sounds.  Genitalia:  Uncircumcised penis, descended testes.  Extremities:  Moving all limbs.  Hips are stable.  Skin:  Negative rash.  Neurologic:  Good head control.  Positive Moro, positive grasp reflexes.

1.  Hearing screen was within normal limits.
2.  Hematocrit was 52% on MM/DD/YYYY.
3.  Metabolic screenings were done on MM/DD/YYYY and MM/DD/YYYY, both results are pending.

DISCHARGE FOLLOWUP:  With Dr. Doe in 3-4 days.

1.  Preterm twin B appropriate for gestational age male newborn infant.
2.  Observed for sepsis.
3.  Mild thrombocytopenia.
4.  Mild hypoglycemia.