SCN Note and Presentation Format

The Special Care Nursery note differs in structure from a SOAP note. To help sort out the complicated issues of intensive neonatal care, a divide and conquer strategy is used. Each system is addressed individually.

This is DOL #35 for this ex-35 week premie with problems including

Jaundice
Rule out sepsis
Gastroesophageal reflux

Respiratory:
Respiratory rate, pulse oximeter readings, vent settings, FiO2. Currrent gases, how obtained (ABG, CBG, VBG?).
#Apneas/bradycardia events
PE: Lung exam.
A&P:

Cardiovascular:
Heart rate, blood pressures
PE: Rate and rhythm of heart, PMI, adventitial sounds, if murmor, where is it loudest. Pulses, capillary refill time.
A&P:

Fluids, Electrolytes and Nutrition:
Today's weight, weight change from previous day.
Ins: Receiving what? Breast feeds, formula (which one?), IV Fluids. Express in cc/kg/day and kcal/kg/day.
Outs: Urine output expressed in cc/kg/h. Urine specific gravities if available. Number and quality of stools.
Electrolytes
A&P:

ID:
Antibiotic day# of #. Present antibiotics.
Status of cultures
PE: Febrile? Other findings related to infection?
A&P:

Heme:
CBC, diff, retic count? Hct, transfusions?
If hyperbilirubinemia: what are current bili levels? Is pt. on lights? What are goals (criteria for d/c of lights or for starting exchange transfusion?)

Neuro:
Head sono results
PE: Neuro exam
A&P:

Other:
Other areas of concern could include other organ systems such as renal, endocrine, etc. Could also address social issues, home care, discharge planning.

Neonatology

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Last modification: July 8, 1997