Medical Records in
NICUs
Introduction
Egyptian neonatal units must collect and
maintain 2 forms of data:
- One involves care of the individual neonate
and requires an accurate individual medical
record.
- The second type of data involves
populations served over time.
Individual and population data can be
analyzed to asses quality, determine needs
and plan for the future.
Introduction
The Egyptian National Neonatal Care Program has
established a data collection system that is standardized
for all units.
The leadership of each neonatal unit is responsible for
identifying with system leader, what data must be
collected and reported and for supervising this process.
The quality of data is very important and can be
maintained with constant attention.
Using birth weights as a basic parameter for comparing
groups of neonates allows for evaluation of unit outcomes.
Learning objectives
1. To know importance of accurate medical records in
NICU.
2. To recognize different types of medical records in
NICU.
3. To identify & know the contents of individual patient
record.
4. To identify & know what is the unit admission book
and its components.
5. To identify monthly report forms and highlight their
importance.
Learning objectives
6. To get acquainted with individual patient
record used in NICUs enrolled in ENNCP.
7. To know what is the necessary information
which have to be fulfilled in infant
admission sheet.
8. To know what is the necessary information
which have to be fulfilled in progress sheet.
9. To know what is the necessary information
which have to be fulfilled in treatment
sheet.
MEDICAL RECORDS IN NICU
There are three areas of responsibility
that require regular supervision:
INDIVIDUAL PATIENT RECORDS.
UNIT ADMISSION BOOK.
MONTHLY REPORT FORMS.
Individual Patient Records
An accurate patient record documents
findings and communicates care plans.
It should be located in the unit & be
available.
Standardize recording forms.
Minimum daily neonatal clinical record, with
more frequent notes if the clinical condition
is unstable or changing is necessary.
Unit Admission Book
Each unit should maintain a record containing
information about every neonate admitted.
The ENNCP has developed a form for this
purpose with specific items to be completed.
Information includes: baby’s name, parents’
names, address and telephone number.
Nursing staff is responsible for the admission
book.
It is a permanent record of the unit activity.
Provides information for monthly report.
Monthly Report Forms
These forms should be completed
monthly and submitted to the Egyptian
National Neonatal Care Program.
Updated summary of monthly activities
help make strong presentations in
support for proposals for new
resources e.g. equipment and
personnel.
Accurate medical records
Assure high quality care.
Improve outcomes.
Help plan for improvements in the
future.
Facilitate patient referral.
Statistics based on medical records
may help identify organisms
implicated in nosocomial infections.
Help following and evaluating
nursing care.
Initial Assessment on Admission
The following has to be included in the
baby’s medical record:
Infant’s data
Parents’ data
Mother’s obstetric history
Resuscitation data
Baby’s vital signs
Initial Assessment on Admission
Baby’s measurements:
wt, length and head circumference
should be plotted on growth chart and
record on which percentile does the
baby fall.
Ballard scoring system has to be done
for every preterm on admission.
Physical examination including all
systems should be done including
neonatal reflexes.
Provisional diagnosis for the baby
should be recorded.
Progress Sheet
The following should be pointed
out clearly daily:
Activity
Vital signs
Measurements: Wt, Length, HC.
Weight should be measured daily &
expressed as + ve or –ve grams from
yesterday’s recording.
Progress Sheet (cont.)
System assessment
Respiratory system
• Respiratory rate.
• Down score: should be done daily for every
baby having respiratory distress.
• Air entry.
• Apnea, bradycardia & desaturations.
• Oxygen saturation of the baby daily.
• X ray findings.
Abdominal examination.
Neurological examination.
Progress Sheet (cont.)
Cardiovascular System
•Heart rate.
•MAP.
•Peripheral pulses.
•Murmurs.
•Drugs.
Infection data
•Baby’s temperature.
•Incubator’s temperature.
•Clinical data.
•CRP, CBC, Culture & Sensitivity, CSF
analysis.
Progress Sheet
• Do investigations timely
CBC, CRP, Ca, G for every baby.
Chest x ray for every baby suffering from
RD.
Na, K for every PT daily.
Treatment Sheet
We have to clearly state the following:
1. Total fluids …ml/kg/d giving…… Kcal/kg/d
2. Parental fluids …ml/kg/d giving… Kcal/kg/d
via PIV or UVC.
3. Enteral fluids …… ml/kg/d…… Kcal/kg/d.
4. Na +:…… meq/kg/d.
K+ :…… meq/kg/d.
Ca++:…… mg elemental ca/kg/d.
GIR:…… mg/kg/hr.
Treatment Sheet
Temperature of incubator should be
written in treatment sheet.
Oxygen mode (whether box or
incubator or nasal prongs) should
be stated in liters/min daily.
We should start antibiotic
treatment with first line Ampicillin
& garamycin.
Summary
To know importance of accurate
medical records in NICU.
To recognize different types of medical
records in NICU.
To identify & know the contents of
individual patient record.
To identify & know what is the unit
admission book and its components.
To identify monthly report forms and
highlight their importance.
Summary
To get acquainted with individual patient
record used in NICUs enrolled in ENNCP.
To know what is the necessary
information which have to be fulfilled in
infant admission sheet.
To know what is the necessary
information which have to be fulfilled in
progress sheet.
To know what is the necessary
information which have to be fulfilled in
treatment sheet.
THANK YOU
