This gives a guideline for reviewing and writing notes on NICU babies to ensure that babies are appropriately assessed and residents use their time efficiently.

• Assess twice daily.
• Write notes twice daily
• Examine Acute problem list
• Assessment Progress in last day
• Observations and assessment
• Plan, reasons and interpretation

• Once in detail (as above). During the day except at weekends.
• Once in brief: Either in the day or at night. At weekends, split these assessments between day and night staff.

• Review daily during the week.
• At weekends, review daily in brief, often on the ward round. Write in notes.

• If asked to review a baby, record appropriate observations and interpretations at the time. Do not wait until the next routine review

Procedures

It is important to document significant procedures undertaken, whether successful or unsuccessful.  Procedures which should be clearly documented (with date and time) include:

• Intubation/reintubation
• Extubation
• Intercostal drain insertion
• Umbilical venous and arterial catheterisation
• Peripheral artery catheterisation
• Longline insertion
• Urinary catheterisation
• Lumbar puncture
• Ventricular tap
• Exchange transfusion
• Institution of non-routine medications should also be clearly documented.

For stable babies, ensure that there is a weekly plan. Avoid duplication (of full assessments and of tests etc.).

• Investigations: Blood tests: day, tick when ordered
• Scans/X-rays/Other
• Drugs: List once weekly or if changed.
• Record levels, date, change, plan.
• Growth/Nutrition: Measure at least weekly.
• Plot growth weekly.
• Respiratory: Part of daily review. Summarise overall course weekly.