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A-1. Discharge Checklist for Provider

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Parents aware of goals for D/C and estimated discharge date: ________

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Initiate D/C checklist 2 weeks prior to estimated discharge date: ________

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Consider consult from follow-up provider for review of complicated discharge: ________

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Diagnostic Tests, Labs, and other Follow-Up

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General

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  • Newborn screen results: ________

  • Congenital heart disease screening: _________

  • Echocardiogram: ________

  • BAER/OAE: ________

  • HPA evaluation, as indicated: ________

  • RUS, as indicated: ________

  • VCUG, as indicated: ________

  • CUS: ________

  • Brain MRI, as indicated. Consider for:

    • HIE

    • Preemie with grade 3 or 4 IVH, cerebellar bleed, or PVL on previous cranial ultrasound

    • Preemie with birth gestational age <26 weeks

    • PPHN treated with HFV and NO (“near miss ECMO”)

    • ECMO for any reason

    • Neonatal seizures

    • Abnormal neurologic examination, inability to orally feed, etc

  • Consider liver ultrasound if ELBW infant to rule out hepatoblastoma if the infant was on long-term HAL with abnormal LFTs: ________

  • Evaluate need for Hip ultrasound due to Breech presentation or abnormal hip examination due 6 weeks postterm: ________

  • Car Seat Test:

    • ________ (first trial)

    • ________ (second trial)

    • ________ Discharge plan, if failed both.

  • Circumcision

  • Complete Discharge Summary

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HIE

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  • MRI: ________

  • PT/OT/ST evaluation

  • Audiology follow-up appt (for possible progressive hearing loss)

  • High-risk clinic follow-up appt

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s/p ECMO

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  • MRI: ________

  • Echocardiogram (post-ECMO) to r/o SVC syndrome:________

  • PFTs: ________

  • Audiology appt (for possible progressive hearing loss)

  • High-risk clinic follow-up appt

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s/p Fundoplication

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  • Evaluation for dumping syndrome: ________

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Myelodysplasia

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  • Checklist completed and appropriate follow-up arranged (see Chapter 38)

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Immunizations and Synagis

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  • Immunizations up-to-date: ________

  • Flu vaccine (if >6 months of age): ________

  • Synagis (All doses and dates should be recorded in discharge summary along with the recommendation to continue monthly though RSV season for PCP):________

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Specialized Parent Teaching

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  • Specific equipment teaching completed: ________

  • Stayed in Care-by-Parent Room: ________

  • Back to Sleep × 3 days (minimum): ________

  • Second-Hand Smoke discussed: ________

  • Lactation breast-feeding plan for home: ________

  • ST/OT feeding plan for home: ________

  • PT exercises for home: ________

  • Dietician teaches formula preparation: ________

  • Solu-Cortef injection teaching, as indicated: ________

  • Infants with VP shunts: teaching regarding s/s of malfunction/ infection: ________

  • Hypoglycemia/glucometer: ________

  • G-tube care: ________

  • Trach changes (three per each immediate care provider)

    • Who ______ Dates______/______/______

    • Who ______ Dates ______/______/______

    • Who______ Dates ______/______/______

  • Other:________

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Psycho/Social

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  • Cleared to be released to home per Social Work: _______

  • Transportation arranged: _______

  • Baby supplies (diapers, clothes, bottles, crib, etc) for home adequate: ________

  • Working phone available: _______

  • Power company has been notified if the infant is technology dependent (home ventilator): _______

  • Interpreter available for discharge:________

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Appointments

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  • Audiology:

  • Cardiology:

  • Early Intervention Services:

  • Endocrine:

  • Genetics:

  • GI:

    ...

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