Appendix D: Chartwork

Many hospitals are now using EMR (electronic medical records) or EHR (electronic health records). These are often in a preformatted template to be completed electronically. Because there are many different formats, there isn't an all-inclusive EMR example. The following section provides an overview of the basic history, progress note, admission orders, and discharge summary. Chapter 6 outlines the newborn physical examination.

1. Identification (ID). State the name, age, sex, and weight of the infant. Include whether the patient or mother was transported from another facility or whether the infant was born at home or within the hospital.

   Infant James, a 3-hour-old 1800-g white male, is an inborn patient from Baltimore, Maryland.

2. Chief complaint (CC). The major problems of the patient are usually listed in the order of severity of disease process or occurrence>.

   1. Respiratory distress syndrome

   2. Suspected neonatal sepsis

   3. Premature birth living child (PBLC)

3. Referring physician. Include the name, address, and telephone number of the referring physician.

   Dr. Macaca Mulatta, Benjamin Franklin Medical Center, Chadds Ford, PA;(946) 854-8881

4. History of present illness (HPI). The HPI is more helpful if it is divided into 4 separate paragraphs.

   1. Initial statement. This part of the HPI includes the patient's name, gestational age, birthweight, sex, age of the mother, and the number of times she has been pregnant along with the number of her living children.

   2. Prenatal history. Discuss the maternal prenatal care and record the number of prenatal clinic visits. Include any medications the mother was taking, any pertinent prenatal tests done, and the results.

   3. Labor and delivery. Include a detailed history of the labor and delivery: type of delivery, type of anesthesia, any medication used, and any fetal monitoring (including results).

   4. Infant history. Discuss the initial condition of the infant and the need for resuscitation, and write a detailed description of what occurred. Include the Apgar scores and discuss when the infant became symptomatic or when problems were first noted.

      Infant James is an 1800-g white male delivered to a 19-year-old G₂ now P₂, LC₂ married white female.

      The mother had excellent prenatal care. She had her first prenatal visit at approximately 8 weeks' gestation and then saw her obstetrician routinely. She was on no medications nor does she have any history of alcohol or cigarette abuse.

      She had rupture of membranes (ROM) at 33 weeks with some mild contractions. At that time, she was seen by her obstetrician, who confirmed the premature rupture of the membranes. She was admitted to the hospital and started on tocolytic treatment in an attempt to stop the labor. Vaginal–rectal swab for GBS cultures were obtained. IV penicillin was initiated. Because of a positive GBS culture, penicillin was continued during tocolysis. External fetal monitoring had been normal until 4 hours after the tocolytic therapy, at which time it showed persistent late decelerations. At this point, an emergency cesarean delivery was performed. General anesthesia was used, and the infant was delivered within 6 minutes.

      The infant was delivered depressed at birth, with 1-minute Apgar of 4. He required bag-mask ventilation with 100% oxygen. No medications were needed. The 5-minute Apgar was 7. The infant appeared poorly perfused and had poor color without oxygen. He was stabilized and transported on 100% oxygen to the NICU.

5. Family history (FH). The family history should include any previous complicated births and their history, miscarriages, neonatal deaths, or premature births. Also include any major family medical problems (eg, hemophilia, sickle cell disease).

   Mrs. James had 1 prior uncomplicated vaginal delivery that went to term. There is a history of myelodysplasia in infant James's maternal first cousin.

6. Social history (SH). In the social history, include a brief statement discussing the parent's age, marital status, siblings, occupation, and where they are from.

   The parents live in Chadds Ford. Mother is a 19-year-old mushroom farm worker and cares for their 2-year-old daughter; the father is 24 years and works in the local museum as a custodial worker.

7. Physical examination. See Chapter 6.

8. Laboratory data. List the admission laboratory and radiology results.

9. Assessment. State your evaluation of the infant's problems. It can include a list of suspected and potential problems as well as a differential diagnosis.

   1. Respiratory distress syndrome: Because the infant is premature, hyaline membrane disease must be considered. Pneumonia is also a likely cause because of the maternal history of suspected chorioamnionitis.

   2. Suspected neonatal sepsis: Because of the positive GBS culture and the premature onset of labor, there is an increased septic risk in this infant. Certain pathogens need to be ruled out. Group B Streptococcus is the most common pathogen in this age group, but Listeria monocytogenes and Gram-negative pathogens should be considered.

   3. Premature birth living child: The infant is at 33 weeks' gestation by Ballard examination.

10. Plan. Include the therapeutic and diagnostic plans for the infant. (See Section on “Admission Orders.”)

The most commonly used format for daily progress notes is the SOAP method. SOAP is an acronym; S = subjective, O = objective, A = assessment, and P = plan. Each problem should be discussed in this format. First, state the problems you are to discuss in the order of severity or occurrence and assign a number to them. Then discuss each problem in the SOAP format as outlined next.

1. Subjective (S). Include an overall subjective view of the patient by the physician.

2. Objective (O). Include data that can be objectively gathered, usually in 3 areas:

   1. Vital signs (temperature, respiratory rate, pulse, blood pressure).

   2. Pertinent physical examination.

   3. Laboratory data and other test results.

3. Assessment (A). Include evaluation of the preceding data.

4. Plan (P). Discuss the medication changes, laboratory orders, and any other new orders as well as the treatment plan.

5. Example. The following is an example of part of a progress note using the SOAP format.

   Problem 1. Respiratory distress syndrome.

   S: Infant James is now 4 days old and doing much better.He has been able to wean down to 30% oxygen with good arterial gases.

   O:Vital signs: temperature 98.7, respirations 52, pulse 140, blood pressure 55/35.

   Physical examination: The peripheral perfusion appears good with no obvious cyanosis. There is no grunting or nasal flaring, but the infant has mild substernal and intercostal retractions. The chest sounds slightly wet. Laboratory data and other test results: Arterial blood gases on 30% oxygen—pH 7.32, CO₂ 48, O₂ 67, 97% saturation. Chest radiograph shows mild haziness in both lung fields.

   A: Infant James has resolving mild respiratory distress syndrome.

   P: The plan is to wean the oxygen as long as his arterial Pao₂ is maintained between >55–70.

   Problem 2. Suspected neonatal sepsis—Follow with “SOAP” note.

   Problem 3. Premature birth living child (PBLC)—Follow with “SOAP” note.

The following format is useful for writing admission orders. It involves the mnemonic A.D.C. VAN DISSEL: Admit, Diagnosis, Condition, Vital signs, Activity, Nursing procedures, Diet, Input and Output, Specific drugs, Symptomatic drugs, Extras, and Laboratory data. Most centers now have online physician ordering templates.

1. Admit. Specify the location of the patient (neonatal intensive care unit, newborn nursery) and the attending physician in charge and the house officer along with their paging numbers.

2. Diagnosis. List the admitting diagnoses.

   1. Respiratory distress syndrome

   2. Suspected neonatal sepsis

   3. Premature birth living child

3. Condition. Note whether the patient is in stable or critical condition.

4. Vital signs. State the desired frequency of monitoring of vital signs. Specify rectal or axillary temperature. Rectal temperature is usually done initially to obtain a core temperature and also to rule out imperforate anus. Then, monitor axillary temperature. Other parameters include blood pressure, pulse, and respiratory rate. Weight, length, and head circumference should also be obtained on admission.

5. Activity. All are at bed rest, but one can specify “minimal stress or hands-off protocol” here. This notation is used for infants who react poorly to stress by dropping their oxygenation, as in patients with persistent pulmonary hypertension. At most centers, it means to handle the infant as little as possible and record all vital signs off the monitor.

6. Nursing procedure. Respiratory care (ventilator settings, chest percussion and postural drainage orders, endotracheal suctioning with frequency). Also require that a daily weight and head circumference be recorded. The frequency of Dextrostix (or Chemstrip-bG) testing is included in this section because it is a bedside procedure.

7. Diet. All infants admitted to the neonatal intensive care unit are usually made NPO (nothing by mouth) for at least 6–24 hours until they are accessed and stabilized. When appropriate, write specific diet orders.

8. Input and output (I and O). Request that the nursing staff record accurate input and output of each infant. This record is especially important for infants on intravenous fluids and those just starting oral feedings. Specify how often you want the urine tested for specific gravity and glucose.

9. Specific drugs. State drugs to be administered, giving specific dosages and routes of administration. It is useful to also include the milligrams-per-kilogram-per-day dose of the drug to allow cross-checking and verification of the dose ordered. An example is as follows:

   Ampicillin 90 mg IV every 12 hours (100 mg/kg/d divided every 12 hours).

   For all infants, order the following medications at the time of admission.

   1. Vitamin K (see Chapter 148) is given to prevent hemorrhagic disease of the newborn.

   2. Erythromycin eye drops (see Chapter 148) are given to prevent gonococcal ophthalmia.

10. Symptomatic drugs. These drugs are not routinely used in a neonatal intensive care unit and would include such items as pain and sleep medications.

11. Extras. Any other orders required but not included previously, such as roentgenography, electrocardiography, and ultrasonography.

12. Laboratory data. Include laboratory data drawn on admission, plus routine laboratory orders with frequency (eg, arterial blood gases every 2 hours, sodium and potassium bid).

The following information is written at the time of discharge and provides a summary of the infant's illness and hospital stay.

1. Date of admission.

2. Date of discharge.

3. Admitting diagnosis.

4. Discharge diagnosis. List in order of occurrence or severity.

5. Attending physician and service caring for the patient.

6. Referring physician and address.

7. Procedures. Include all invasive procedures.

8. Brief history, physical examination, and laboratory data on admission. Use the admission history, physical examination, and laboratory data as a guide.

9. Hospital course. The easiest way to approach this section of the discharge summary is to discuss each problem in paragraph form.

10. Condition at discharge. A complete physical examination is done at the time of discharge and included in this section. It is important to include the discharge weight, head circumference, and length so that growth can be assessed at the time of the patient's initial checkup. Also include the type and amount of formula the patient is on and any pertinent discharge laboratory values.

11. Discharge medications. Include the name(s) of medication(s), the dosage(s), and length of treatment. If the patient is being sent home on an apnea monitor, it is helpful to include the monitor settings and the planned course of treatment.

12. Disposition. Note where the patient is being sent (outside hospital, home, foster home).

13. Discharge instructions and follow-up. Include instructions to the parents on medications and when the patient is to return to the clinic (and exact location). It is helpful to indicate tests that need to be done on follow-up and any results that need to be rechecked (eg, bilirubin, repeat phenylketonuria screen).

14. Problem list. Same list as the discharge diagnosis list.