Sheet No:

Progress Note
Chattagram Metropoliton Hashpatal Ltd.
698/752, O.R Nizam Road, Chittagong, Bangladesh
Phone: 2852670-3, 651242, 652750.
S – D/O: PNA: hours/ days, Hospital Stay: hours /days, Inborn /Outborn

Diagnosis:
 Term (......weekers), AGA (...........gms), with
 Term (......weekers), LBW (...........gms), IUGR with
 Term (......weekers), LGA (...........gms) with
 Preterm (......weekers), LBW/VLBW/ELBW (...........gms), AGA/SGA/IUGR/LGA with
 Preterm (......weekers), AGA (...........gms) with

Baby is Getting...........................................................................................

Follow Up According to SOAP Method:

Date: / / 20 Time: AM/PM
A)Subjective:
1.
2.
3.
4.
B) Objective:
Activity: Sucking: Good / Poor/ Absent.
Color: Pink/ Cyanosed in Room Air, ........... L/min O2 with Nasal
Cannula / Head Box, CPAP/ Ventilator with FIO2: %

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Color: Icteric Extends upto Face /Chest/ Abdomen / Palms and Soles
Respiratory Rate: /min, Heart Rate: beats/min
Temperature: /F (Axilary Over 3 minutes), CRT: Sec
SpO2: % with Room Air, ..........L/Min O2, FiO2: .........%
Capillary Blood Glucose: mmol/l with GIR: mg/kg/min
First and Second Heart Sound Audible in 4 Auscultatory Areas, having no
Murmur/ having a Systolic – Continuous - Pansystolic Murmur.

Air Entry: Symmetrical / Good / Poor in both Lungs Field.

Abdomen: Normal / Distended / Not Distended/ Shiny/Loopy, Bowel Sound: Present / Absent,
Umbilicus: Healthy (with .....Vein and .... Arteries Present) & 7.1% Chlorhexidine: Applied / Pending
(within 48 Hours, Single Use then Dry Cord Care)

Genitalia: Male - Female Pattern / Ambiguous, Testes: Descended / Undescended, Inguinal

Hernia: A/P, Hydrocele: A/P, Hypospadius/ Epispadius: A/P

Anus: Patent / Absent

Back & Spine: Normal / NTDs (If Present Evaluate)
Urine: Passed, Yet not Passed, .......times over last 24 hours
Stool / Meconium: Passed, Yet not Passed, .....times over last 24 hours
Birth Weight: gms, Current Weight: gms, Wt Loss:
%
OFC: CM Length: CM

Any Special Finding (with Details):

...............................................................................
...............................................................................
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C) Assessment: Improving / Deteriorating

D)Plan (Regarding Temperature, Oxygen, Feed, Fluid, Antibiotics,

Investigations, Transfer Step down/up, Refer, Discharge, On Call,
Procedures, Counseling, Screening etc.)
1.
2.
3.
4.
...........................................

(Signature with Date)

Dr...........................................

(Full Name)

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 On Call Note / Decisions has been Taken By the Board

Date: / /20 Time: AM/PM

Indications:

1.

2.

Detailed Decisions:

.....................................................................................................................

.....................................................................................................................

.....................................................................................................................

Board Members:

1.

2.

Plan of Investigations:

 ABG Analysis
 CXR
 Sepsis Screening (CBC with PBF, IT ratio & ANC, CRP) and Blood C/S
 RBS
 Serum Electrolyte
 Serum Calcium
 Serum Creatinine
 Blood Grouping & Rh Typing
 Serum Bilirubin (Total, Indirect, Direct)

Plan of Management:

 TABC (Including Open Warmer, Cot, Suction, Oxygen with Nasal, Headbox, CPAP,
Ventilator Support)

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 Fluid: Type & ml/kg According to PNA with or without curtailed
 Aminoacid (starting dose: 20 ml/kg)
 Feed: Type (breast / formula/ lone), Mode (IV-OG/NG-Cup& Spoon-Breast), Amount:
Trophic / Demand
 Antibiotics: First / Second / Third line
 Anti-convulsants: Inj. Phenobarbitone- Loading, 10 mg/kg or Maintenance
 Loading Glucose (2 ml/kg) and or Calcium (2 ml/kg)
 Normal Saline loading and or Inj Dopamine (5 microgram/kg/min)
 Phototherapy / Exchange Transfusion