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