NICU DISCHARGE/INTERIM SUMMARY DICTATION PROCEDURE
Department of Neonatology - Beth Israel Deaconess Medical Center
Dial 7-4503 or (toll free) 877-517-0462
Enter your dictation number: ___ ___ ___ ___ ___ followed by “#”:
42677
50-580
50-123
50-113
50-115
50-124
Aslam
Brodsky
Buck
Burris
Dukhovny
Fleck
50-470
94131
35625
50-125
50-549
50-276
Gray
Gregory
Gupta
Guthrie
Hansen
Lee
50-331
50-595
50-442
41361
50-132
50-454
Madden
Martin
McAlmon
O'Reilly
Ouellette
Pursley
50-129
50-002
50-127
50-128
50-393
36353
Quinn
Rhein
Rivers
St. Germain
Schechner
Severson
50-240
50-466
50-309
50-569
50-130
50-622
50-131
Smth
Stewart
Tannenbaum
Tran
Whitlock
Zupancic
Zaccagnini
Enter number followed by “#”:
 10# - STAT Discharge Summary
 2# - Discharge Summary
 3# - Discharge Summary Addendum
Enter 7-digit patient MR#: _ _ _ _ _ _ _ followed by “#”
DICTATION OPERATING CONTROLS
Begin dictation when you hear the tone:
1#
Listen
1. Name of dictator [spell name].
2#
Dictate
3#
Short Review
2. Name of attending [spell name].
4#
Pause
3. Patient's name [spell name].
5#
Separate Reports
[Use only “Boy” or “Girl” for first name.]
6#
Go To End of Dictation
7#
Fast Forward
4. Service (“Neonatology”).
8#
Reverse To Beginning
5. Patient unit number.
9#
Disconnect and Obtain Job Number
6. Date of birth and sex of patient.
*
To Clear An Incorrect Mode
7. Date of admission.
8. Date of discharge. [A date must be entered.] If interim summary, state “interim date.”
9. History:
a. This patient’s post-discharge name is (spell name). [Then start new paragraph.]
b. If interim summary, specify dates covered and author/date of prior summary.
c. Include reason for admission, birth weight, gestational age.
d. Maternal history-including prenatal labs, pregnancy, labor, and birth history.
10. Physical examination at discharge:
a. Include weight, head circumference, and length – note percentile.
11. Summary of hospital course by systems (concise). Include pertinent lab results:

Respiratory - Initial impression. Surfactant given? Maximum level of support. Days
on ventilation, CPAP, supplemental oxygen. If apnea, only report how patient was
treated, when treatment ended and condition resolved.

Cardiovascular - Diagnoses/therapies in summary form. Echo/ECG results.

Fluids, Electrolytes, Nutrition - Brief feeding history. Include recent weight, length
and head circumference.

GI - Pertinent diagnoses and treatment. Maximum bilirubin and therapy used.

Hematology - Patient blood type, brief transfusion summary, recent Hct.

Infectious Disease - Cultures, colonization if appropriate, antibiotic courses.

Neurology - Describe ultrasound findings.

Sensory:
i. Audiology: “Hearing screening was performed with automated auditory
brainstem responses.” Results. [If baby didn’t pass, indicate date/location of
follow-up testing. If not done, recommend test prior to discharge.]
ii. Ophthalmology:

“Patient did not meet criteria for screening exam.”

“Not Examined: Patient is due for a first exam on __________.”
“Immature: Eyes examined most recently on _________ revealing
immaturity of the retinal vessels but no ROP as of yet. A follow-up
examination should be scheduled for the week of __________.”
12.
13.
14.
15.
16.
17.
18.
 “ROP: Eyes examined most recently on _________, revealing ROP
___________________.
A follow-up examination by a pediatric
ophthalmologist should be scheduled for __________.”
 “Mature: Eyes were examined most recently on __________, revealing mature
retinal vessels. A follow-up exam is recommended in 6 months.”
iii. Psychosocial: “BIDMC Social Work involved with family. The contact social worker is
[name], and she can be reached at 667-4700. Follow-up will be provided by [name of
agency/social worker and telephone number]”. [If applicable, “A 51-A has been filed."]
Condition at discharge.
Discharge disposition (e.g.” home,” “Level II,” “Level III,” “chronic care”)
Name of primary pediatrician (spell name). Phone #: ________ Fax #: ________
Care/recommendations (quick summary for those assuming care of the infant).
a.
Feeds at discharge. [If NeoSure/EnfaCare, recommend until 6-9 months corrected age.]
b.
Medications. [Include each medication with dose (concentration if volume), route,
frequency.]
c.
Iron and Vitamin D supplementation:
i.
Iron supplementation is recommended for preterm and low birth weight infants
until 12 months corrected age.
ii.
All infants should receive vitamin D supplementation at 400 International Units
daily. This may be achieved by administering D-Vi-Sol or a multivitamin
preparation with vitamin D. Once formula fed infants achieve a daily volume
intake of 1 liter, supplements may be discontinued. All other infants should
continue to receive supplementation.
d.
Car seat position screening (if < 37 weeks gestation) or fit assessment (if term and
< 2500g) results.
e.
State newborn screening status.
f.
Immunizations received.
g.
Immunizations recommended [Dictate verbatim]:
i.
“Synagis RSV prophylaxis should be considered from November through March
for infants who meet any of the following criteria: 1) gestational age at birth < 32
0/7 weeks; 2) gestational age at birth 32 0/7 to 34 6/7 wks and either attend
childcare or live with other children under five years of age; 3) chronic lung
disease; 4) hemodynamically significant CHD; or 5) congenital abnormalities of
the airway or neuromuscular disease (if born before 35 weeks gestation).”
ii.
“Influenza immunization is recommended annually in the fall for all infants once
they reach 6 months of age. Before this age (and for the first 24 months of the
child’s life), immunization against influenza is recommended for household
contacts and out-of-home caregivers.”
iii. “Updated pertussis immunization is recommended for adults having contact with
infants.”
iv.
“This infant has not received rotavirus vaccine. The American Academy of
Pediatrics recommends initial vaccination of preterm infants at or following
discharge from the hospital if clinically stable and chronologic age is between
6 weeks and 14 weeks 6 days.”
h.
Follow-up appointments scheduled/recommended [Include physician, clinic or
department.]
Discharge Diagnoses List. [Be complete; this is used by medical records coders.]
Re-state name of attending [spell name].
Multiple reports- press 5 to separate. Press 9 at end of report before hanging up.
Revised: 6/25/2010