Neonatology Rapid Response Note

PAT004 CPR Policy Appendix Q Neonatology RRT
DEPARTMENT OF PEDIATRICS
NEONATOLOGY RAPID RESPONSE NOTE
Date: ____________
Time: ____________
for addressograph plate
Called to location for: ____________________________________________________________________________________________
Maternal History:
Age: __________ yrs.
Race: ____
Gestational Age: __________(dates) __________(exam) __________(sono)
Prenatal complications :__________________________________________________________________________________________________
___________________________________________________________________________________________________________________
Intrapartum:
ROM: ______________(date)
______________(time)
Antibiotics: _____________________________________________
______________(duration in hours)
Mode of delivery: _____________________________________________
Other complications: ____________________________________________________________________________________________________
___________________________________________________________________________________________________________________
Infant:
Time of birth: ____________________
Sex: ____________________
Birth weight: ____________________ gm
Initial Appearance: _____________________________________________________________________________________________________
Meconium: ____________
APGAR
Score
Heart Rate
1 min.
Intubation / tracheal suction: ____________
5 min.
10 min.
15 min.
Meconium below VC: ____________
20 min.
Physical Exam:
HEENT ____________________________________________
Resp. Effort
Palate ______________________________________________
Tone
Neck / Back _________________________________________
Reflex
Clavicles ___________________________________________
Color
Chest ______________________________________________
Total
Cardiovascular_______________________________________
Abdomen ___________________________________________
Yes
No
Comments
Umbilical cord_______________________________________
Genitalia____________________________________________
Oxygen
Extremities__________________________________________
Neurologic__________________________________________
CPAP
Other ______________________________________________
___________________________________________________
PPV/T-piece
resuscitator
ETT
Chest
compressions
___________________________________________________
Comments: ________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
Plan: _____________________________________________
___________________________________________________
Epinephrine /
volume
___________________________________________________
__________________________________________________
NICU Nurse:____________________________________________, RN
Respiratory Therapist: ____________________________________, RRT
House Officer: ___________________,MD ___________Physician ID
Fellow: _________________________,MD ___________Physician ID
04-480531700712 (8/09)
I attended the delivery / supervised the resuscitation of this infant
performed by Dr_________________ (Fellow).
Attending:_______________________,MD ___________Physician ID