Appendix D: Chartwork

INTRODUCTION

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.

ADMISSION HISTORY

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. ...