Department of Neonatology
Beth Israel Deaconess Medical Center
Policy and Procedure
Title:
Physician and Mid-Level Provider Documentation
Policy #:
CL-1
Purpose: To describe physician and mid-level provider documentation expectations for newborns in the
Neonatal ICU.
Policy Statement: Medical care documentation should enhance care by providing other care
providers with an accurate description of clinical findings and interventions while complying with all state
and federal laws.
Guideline for Implementation:
1. Admissions
a. Sepsis Evaluations
A note documenting sepsis risk, benign exam, impression (generally, asymptomatic newborn with
sepsis risk), and plan (per Guidelines for Management of “Well-Appearing” Infants at Risk for
Sepsis) should be written by the neonatologist and any other clinician who holds primary
responsibility for the patient in the NICU. The exam may be documented on the Physician’s
Record of Newborn Infant form. The diagnosis, "R/O Sepsis", should be noted in the admission
column of the "Physician's Record of Newborn Infant" form, but the remainder of this form should
be left for the newborn nursery physician to complete. Orders for a CBC, blood culture, and blood
glucose, and for transfer of the patient to the nursery, should be written.
b. Acute Illness and Monitoring
A note documenting relevant antepartum and intrapartum history, delivery room events,
comprehensive exam, laboratory data, impression including diagnoses, and plan should be written
by the neonatologist and any other clinician who holds primary responsibility for the patient in the
NICU. The "Physician's Record of Newborn Infant" form should be completed and signed
(although the exam portion may refer to an exam documented in the body of the admitting note).
2.
Progress
A comprehensive note, summarizing the daily clinical status of the newborn, should be written by
the neonatologist and primary clinician (NP/PA, medical student, fellow). A note should be
written on the day of discharge and should include elements of discharge planning and follow-up.
3.
Incidental
A physician (neonatologist or pediatrician) or NP/PA note should document any significant
clinical events (apart from the daily progress note), including lab results, radiology and other study
findings, and other significant findings or interventions.
Policy #CL-1: Page 1 of 3
4.
Procedures
The procedure note should be clearly identified. It should include the following information: type
of procedure, consent (if indicated), “Time-Out” procedures, indication, monitoring,
preparation/positioning, pre-operative medications (if any), technique, results, confirming studies
(e.g. CXR for ETT position), and brief description of outcome (e.g. "... tolerated well ...").
5.
Transfer of Care within the NICU
A dated and timed order or incidental note should document the transfer of care to, or from, a nonfaculty neonatologist.
6.
Transfers to Newborn Nursery
A note documenting resolution of the conditions or diagnoses responsible for the initial admission
should be written prior to transfer to the nursery (does not replace need to contact the BIDMC
pediatrician accepting care). A discharge summary should be dictated for any baby whose NICU
length of stay spans two midnights.
7.
Discharges (including retro- and level III transfer)
A dictated discharge summary is required. A written discharge summary can be provided for
transfer summaries, but this does not preclude the need for a dictated discharge summary, which
should be completed and faxed, to the receiving facility within 24 hours of the transfer.
NICU discharge summaries may be done by an attending neonatologist or by a fellow, neonatal
mid-level provider, or medical student. The latter three individuals may dictate a summary, but it
would require co-signature by an attending physician. In general, all babies discharged from the
NICU should have a dictated discharge summary. This includes deaths and transfers.
Furthermore, all babies who spend more than a day in the NICU, regardless of whether or not they
are discharged from the NICU, should also have dictated discharge summaries. Because the
timing of transfer from the NICU might be difficult to ascertain, any baby who spends two
midnights in the NICU (e.g. admitted on March 21 and transferred on March 23) should have a
dictated summary.
Assignment of these dictations and outstanding discharge signatures should be to that
neonatologist who is recognized as the infant's attending at the time of discharge. In the great
majority of cases, the attending neonatologist will be the individual indicated on the monthly
attending schedule. In some cases, it is conceivable that this attending neonatologist may not have
had any involvement in the care of an infant prior to discharge. This might occur in a situation
where an infant is acutely discharged from a unit on a night or a weekend. In these cases the
monthly attending will notify the medical record department that the chart should be assigned to
the attending primarily involved in the baby's care.
The discharge column of the "Physician's Record of Newborn Infant" should be completeddocumenting the discharge exam and discharge diagnoses- and include the signature of the
examining provider.
Policy #CL-1: Page 2 of 3
The discharge summary must be electronically signed by the attending physician, and the
discharge exam on the "Physician's Record of Newborn Infant" must be co-signed by the attending
physician.
8.
NP/PA Orders
NP/PA orders for narcotics, muscle relaxants, and digoxin should be co-signed by the attending
physician.
9.
Delivery Room Management
Attendance and care administered at a high-risk delivery should be noted on the appropriate
newborn form. Similarly, any evaluation of an infant in the DR that does not result in NICU
admission should be documented. For infants who are admitted to the NICU, the documentation
of the DR evaluation can be included in the admission note.
10.
Antepartum Consultation
Any antepartum consultation, not directly provided by the attending, should be followed up by the
neonatologist and the consultation form completed, signed, and placed in the maternal record
within 30 hours of request. These notes should be written on the Antepartum Consultation Form.
The original should be placed in the maternal medical record, and the copy should be placed in the
Prenatal Expect binder. The patient, medical record number, and other pertinent information
should be written in the tracking form in the front of the binder.
11.
Newborn Nursery Consultation
These consultation notes should be written directly in the newborn record.
12.
End-of-Month "Off Service"
The fellow coming off service should write or dictate a summary of each of his/her patient's
courses-to-date at the end of his/her month.
Appendices: None
Version: 10/11/01; revised 11/04/04, revised 4/13/09
Policy #CL-1: Page 3 of 3