SUM
SUM Hospital
Neonatal Medical Record Form
Form Sections
General Information
Registration / Birth Details
Maternal Details
Medical Problems (Mother)
Obstetric Problems
Labour / Delivery
Neonatal Details
Neonatal Details
Respiratory Distress
CNS Disorders
Major Malformations
Neonatal Infections
Miscellaneous Morbidity
Treatment
Maternal Death
Other Information
General Information
Centre Code
Baby's Hospital Record No.
High Risk Baby
Select High Risk Baby
Yes
No
Readmission
Select Readmission
Yes
No
Registration / Birth Details
Mother's Name
Father's Name
Date of Birth (dd/mm/yyyy)
Time of Birth (24 Hrs)
Sex
Select Sex
Male
Female
Birth Weight
Gestation (best estimate)
Mode of Delivery
Select Mode of Delivery
Normal
Cesarean
Forceps
Vacuum
Baby Attended at Birth by
Apgar 1 min
Apgar 5 min
Apgar 10 min
Single / Multiple
Select Single / Multiple
Single
Twin
Triplet
Other
Address
Tel Number
Mother Blood Group
Select Mother Blood Group
A+
A-
B+
B-
AB+
AB-
O+
O-
Baby Blood Group
Select Baby Blood Group
A+
A-
B+
B-
AB+
AB-
O+
O-
Hearing Screening - Left Ear
Select Hearing Screening - Left Ear
Pass
Fail
Not Done
Hearing Screening - Right Ear
Select Hearing Screening - Right Ear
Pass
Fail
Not Done
Red Reflex
Select Red Reflex
Present
Absent
Not Done
Maternal Details
Mother CR No
Unit
Maternal Age
Gravida
Para
Abortion
Still Birth
Previous IUGR
Select Previous IUGR
Yes
No
Antenatal Care
Select Antenatal Care
Yes
No
Medical Problems (Mother)
Diabetes (other than GDM)
Select Diabetes (other than GDM)
Yes
No
Heart Disease
Select Heart Disease
Yes
No
Renal Disease
Select Renal Disease
Yes
No
Hypertension
Select Hypertension
Yes
No
Seizure Disorder
Select Seizure Disorder
Yes
No
Tuberculosis
Select Tuberculosis
Yes
No
Malaria
Select Malaria
Yes
No
Asthma
Select Asthma
Yes
No
Hepatitis B
Select Hepatitis B
Yes
No
Syphilis
Select Syphilis
Yes
No
HIV Infection
Select HIV Infection
Yes
No
Booked
Select Booked
Yes
No
Others
Obstetric Problems
Severe Anemia (Hb < 7 g/dl)
Select Severe Anemia (Hb < 7 g/dl)
Yes
No
Pregnancy Induced Hypertension
Select Pregnancy Induced Hypertension
Yes
No
Pre-eclamptic Toxaemia
Select Pre-eclamptic Toxaemia
Yes
No
Eclampsia
Select Eclampsia
Yes
No
Gestational Diabetes
Select Gestational Diabetes
Yes
No
Oligohydramnios
Select Oligohydramnios
Yes
No
Polyhydramnios
Select Polyhydramnios
Yes
No
Cephalopelvic Disproportion
Select Cephalopelvic Disproportion
Yes
No
Previous Caesarean Delivery
Select Previous Caesarean Delivery
Yes
No
Antepartum Haemorrhage
Select Antepartum Haemorrhage
Yes
No
Placenta Previa
Select Placenta Previa
Yes
No
Abruptio Placentae
Select Abruptio Placentae
Yes
No
Others
Labour / Delivery
Non-vertex Presentation
Select Non-vertex Presentation
Yes
No
Oxytocin Use
Select Oxytocin Use
Yes
No
Prolonged ROM (> 18h)
Select Prolonged ROM (> 18h)
Yes
No
Meconium Stained Liquor
Select Meconium Stained Liquor
Yes
No
Foul Smelling Liquor
Select Foul Smelling Liquor
Yes
No
Fetal Bradycardia (< 120)
Select Fetal Bradycardia (< 120)
Yes
No
Fetal Tachycardia (> 160)
Select Fetal Tachycardia (> 160)
Yes
No
Antenatal Steroid
Select Antenatal Steroid
Yes
No
Neonatal Details - Resuscitation
Oxygen
Select Oxygen
Yes
No
Bag and Mask
Select Bag and Mask
Yes
No
Chest Compression
Select Chest Compression
Yes
No
Intubation for Meconium
Select Intubation for Meconium
Yes
No
Intubation Otherwise
Select Intubation Otherwise
Yes
No
Adrenaline
Select Adrenaline
Yes
No
Volume Expanders
Select Volume Expanders
Yes
No
Neonatal Details - Morbidity
Received Nursery Care > 12 hr
Select Received Nursery Care > 12 hr
Yes
No
Respiratory Distress
Transient Tachypnoea / Delayed Adaptation
Select Transient Tachypnoea / Delayed Adaptation
Yes
No
Pneumonia
Select Pneumonia
Yes
No
Meconium Aspiration
Select Meconium Aspiration
Yes
No
Hyaline Membrane Disease
Select Hyaline Membrane Disease
Yes
No
Pneumothorax
Select Pneumothorax
Yes
No
Others
CNS Disorders
Hypoxic Ischaemic Encephalopathy
Select Hypoxic Ischaemic Encephalopathy
Yes
No
Seizures
Select Seizures
Yes
No
IVH
Select IVH
Yes
No
Other Intracranial Bleed
Select Other Intracranial Bleed
Yes
No
Others
Major Malformations
Cardiac Malformation
Select Cardiac Malformation
Yes
No
Hydrocephalus
Select Hydrocephalus
Yes
No
Neural Tube Defect
Select Neural Tube Defect
Yes
No
Cleft Lip / Palate
Select Cleft Lip / Palate
Yes
No
Gastrointestinal Malformation
Select Gastrointestinal Malformation
Yes
No
Genitourinary Malformation
Select Genitourinary Malformation
Yes
No
Down Syndrome
Select Down Syndrome
Yes
No
Others
Neonatal Infections
Pyoderma
Select Pyoderma
Yes
No
Umbilical Sepsis
Select Umbilical Sepsis
Yes
No
Conjunctivitis
Select Conjunctivitis
Yes
No
Thrush
Select Thrush
Yes
No
Septicemia / Pneumonia / Meningitis
Select Septicemia / Pneumonia / Meningitis
Yes
No
Tetanus Neonatorum
Select Tetanus Neonatorum
Yes
No
Others
Systemic Sepsis
Select Systemic Sepsis
Yes
No
Miscellaneous Morbidity
Hyperbilirubinemia (Need for Phototherapy)
Select Hyperbilirubinemia (Need for Phototherapy)
Yes
No
Rh Isoimmunisation
Select Rh Isoimmunisation
Yes
No
Hypothermia
Select Hypothermia
Yes
No
Apnoeic Spell(s)
Select Apnoeic Spell(s)
Yes
No
Hypoglycaemia
Select Hypoglycaemia
Yes
No
Hypocalcaemia
Select Hypocalcaemia
Yes
No
Anaemia
Select Anaemia
Yes
No
Polycythaemia
Select Polycythaemia
Yes
No
NEC
Select NEC
Yes
No
ROP
Select ROP
Yes
No
PDA
Select PDA
Yes
No
Vitamin K Deficiency Bleeding
Select Vitamin K Deficiency Bleeding
Yes
No
Neonatal Cholestasis
Select Neonatal Cholestasis
Yes
No
Major Birth Trauma
Select Major Birth Trauma
Yes
No
CLD
Select CLD
Yes
No
Other
Treatment
IV Fluids
Select IV Fluids
Yes
No
Antibiotic(s)
Select Antibiotic(s)
Yes
No
Oxygen
Select Oxygen
Yes
No
Oxygen Duration
CPAP
Select CPAP
Yes
No
CPAP Duration
IMV
Select IMV
Yes
No
IMV Duration
Surfactant
Select Surfactant
Yes
No
Blood/Plasma Transfusion
Select Blood/Plasma Transfusion
Yes
No
Phototherapy
Select Phototherapy
Yes
No
Exchange Transfusion(s)
Select Exchange Transfusion(s)
Yes
No
Parenteral Nutrition
Select Parenteral Nutrition
Yes
No
Laser for ROP
Select Laser for ROP
Yes
No
Any Other Surgery
Select Any Other Surgery
Yes
No
Maternal Death
Did the Mother Die?
Select Did the Mother Die?
Yes
No
Other Information
Hospital Course
Select Hospital Course
Good
Fair
Poor
Diagnosis
Date of Discharge (dd/mm/yyyy)
Weight at Discharge
Head Circumference
Icterus at Discharge
Select Icterus at Discharge
Yes
No
Intrauterine Growth Category
Select Intrauterine Growth Category
AGA
SGA
LGA
NNPD Number
Date Entered By
Supervised By
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