Appendix A: Discharge Checklists

A-1. Discharge Checklist for Provider

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

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

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

Diagnostic Tests, Labs, and other Follow-Up

General

• 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

HIE

• MRI: ________

• PT/OT/ST evaluation

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

• High-risk clinic follow-up appt

s/p ECMO

• MRI: ________

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

• PFTs: ________

• Audiology appt (for possible progressive hearing loss)

• High-risk clinic follow-up appt

s/p Fundoplication

• Evaluation for dumping syndrome: ________

Myelodysplasia

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

Immunizations and Synagis

• 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):________

Specialized Parent Teaching

• 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:________

Psycho/Social

• 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:________