NEONATOLOGY CASE REPORT FORMAT

The purpose of this exercise is to assess your ability to synthesize information gathered from a neonate’s
case notes, referral letter from obstetrics to paediatrics, and antenatal card to construct a diagnosis, then
discuss the management of the patient. We would like to see critical thinking and analytical writing skills,
specifically your ability to articulate ideas clearly and effectively.

At the top of the case report, please state your full name, student number and type of report (Neonatal
or Paediatric). Please also ensure that the patient hospital registration number (Not IC number) and date
of admission are on the document.

Please save your file in MS Word and name the uploaded files as follows: (yourname_neonatal.doc)

Gathering information for neonatal case write-ups

Information for the history in neonates has to be gathered from a variety of places. The mother is seldom
the main source of history and students will need to gather information off the obstetric referral sheet,
antenatal card and in some cases may need to go back and look at the mother’s obstetric record. When
babies are referred directly from the O&G department the mother is often unaware of the baby’s problems
and it is the neonatal doctors caring for the baby who gives this information to the mother. Details of
obstetric history and birth should be obtained from the medical records where-ever possible and not the
mother. Ask her for her antenatal card so that you can get accurate antenatal and birth information. Go
back to the obstetric notes if possible.

1. For a baby admitted immediately after birth Identifying

A. Details
B/O:
RN:
Date of admission:
Date of clerking:
Date of birth:
Age on admission:
Current gestational age:
Gestational age at birth:
Birth weight, length, and head circumference (plot on the growth charts)

B. Chief complaint or reason for admission

C. Relevant antenatal history

● Mother’s conception (to understand what parents are going through, whether it was a wanted or
unwanted pregnancy and social factors eg baby is a result of rape or incest), pregnancy and delivery
history. Any relevant information about previous abortions, stillbirths and neonatal deaths and
living children (these will affect how the parents are feeling about this baby)
● How gestation was determined, when antenatal care started, any antenatal malformation or dating
ultrasound scans, when scanned and relevant results. (Unless you are clear about the dating process
and also how accurate are the dates, you are unable to properly recognize SGA and LGA. It is a bad
habit to simply accept the dates given by O&G department)
Updated 1.6.23
 ● Any complications during pregnancy and how these were managed, any relevant investigations
done during antenatal care.

D. Delivery Details
Type of delivery, condition at birth and any delivery room management

E. Initial Findings and management in neonatal unit including any investigations done and their
results.
Describe the initial examination findings and condition of the baby on arrival in the ward and what
was done for the baby. (What did the HO or initial attending doctor do for this patient)? Give the
results of investigations done at this time and interpret these. Include initial X-ray findings. Give
results of subsequent results if relevant. Show that you understand this phase of management.

F. Progress notes
Brief summary of baby’s progress. Describe if the condition has improved e.g. the respiratory rate is
now normal, the subcostal recession has resolved etc and the baby has gained weight or perhaps
dropped several centiles etc. Have a general idea of the management that was carried subsequently
but you do not need to describe the infants daily progress in detail.

G. Discussion of the case.

The discussion should focus on showing that you understand the diagnosis, investigation and
management of the patient. You should avoid giving details from textbooks. References are
not mandatory but you may use them to support your arguments if necessary.

H. References

2. For babies readmitted after going home

Information for the history of what happened between discharge from hospital at birth and readmission
is usually from the mother. So in addition to the details mentioned in Section A, B, C, D, E, F, and G
above, you will need to include a history of what happened at home eg feeding history and immunization
is required.

Updated 1.6.23
Marking rubric indicating maximum marks for each level

1 2 3 4
Level
Max 7 marks Max 15 marks Max 22 marks Max 30 marks
Minimal history History and As per Level 2 AND As per Level 3 AND
and examination examination reported in a presented with accurate
findings relevant findings relevant manner that and detailed descriptions
to the case with to the case are makes it clear of the problems and
important pieces complete. what the diagnosis issues central to the case;
of information is. provides a well-focused
History and
missing Details needed to diagnosis and key
physical
know the severity problems that
examination
of the disease is demonstrates an
30%
mentioned. excellent grasp of the
Other associated patient holistically.
problems the
patient faced is
mentioned

3 5 8 10
Just copied As per Level 1 with As per level 2 with As per level 3 and
Management investigations and the addition of the addition of reasons why the
(including management plans reporting what the interpreting what investigations were
investigations) from patient’s investigation the investigation needed.
(10%) chart results showed results mean

1 2 4 5
Very brief notes Fairly complete Patient’s progress Patient’s progress and
about the patient’s notes about the and management management plans /
progress over the patient’s progress plans / changes changes summarized
duration of over the duration written concisely concisely in one
admission just of admission but in a paragraph. paragraph, with clear
Progress notes copied off the they were just descriptions on how the
(5%) patient’s chart. copied off the patient responded to the
patient’s chart. management and details
about why changes were
made following his
progress/investigation
results.

Updated 1.6.23
 2 3 4 5
Some parts plotted All parts plotted All parts plotted Everything plotted
correctly correctly correctly, and correctly and
Growth chart
some interpretation of the
(5%)
interpretation values correlated with
given patient’s condition

12 24 36 50
Simply repeats A fair discussion Discussion is Detailed synthesis of
information. Does with some adequate and available information to
not discuss the information tied mostly tied back to provide clear justification
relevance of this back to the case. A facts of case. about how the diagnosis
information to the lot of gaps in It addresses most and related problems
case. addressing issues of the issues in the came about. Described
A lot of present in the case. how the investigations
misinformation case. Very little contributed to
Discussion (50%)
present in the May have some misinformation management plans.
discussion. misinformation in present Demonstrates good
the discussion understanding about why
the management plans
were chosen and is
supported with relevant
literature.

Evidence based question

As part of the neonatal case report, each student will need to answer an evidence-based question
related to the case.

The purpose of the assignment is to assess your ability to:

1. Ask an answerable question that would be of use either to the patient in the neonatal writeup or
about some aspect of the management used in the patient – what is the evidence for this
treatment? It could also be about a question the parents might ask about the future of the baby.
2. Use PICO to find a research paper that will answer the question
3. Appraise the selected paper and discuss the applicability of the results to the patient

You are encouraged to discuss the selection of the question and search terms with one of the
lecturers to avoid pitfalls in this exercise.

1. Select an aspect on management of the baby that you would like to know more about (General
Question)
Type of questions include some form of treatment the baby did or didn’t receive, or it may be about
something that they parents might ask about the prognosis of the baby or whether there is anything

Updated 1.6.23
 the parents can do at home to improve the outcome (such as breastfeed, massage etc). It might also
cover the diagnostic process, for example, whether a certain investigation is useful in picking up the
condition.

2. Reformat the above using PICO

3. Select terms and search the appropriate database (Cochrane Library or MEDLINE). Display your search
strategy and search results
4. Select an article from the above. DO NOT SELECT AN ARTICLE FIRST AND THEN MAKE UP SOME PICO
FROM THE ARTICLE.

5. Using the selected article:

a. Write the name of the article and the correct citation using a standard format (authors, title,
journal, year, volume, page numbers).
b. Write a brief summary of article. (Do not copy the abstract). This only needs to be 2-4
sentences stating the study design, the patients, the intervention or indicator and the main
result. A good summary is one that will show the reader whether the article meets your PICO.

6. Critically appraise it using the appropriate critical appraisal worksheet. (Critical appraisal sheets for
each type of clinical question can be found on the EBM or Paediatric Moodle site)

For the section:

a. “How were the results represented?”, mention the type of analysis done eg relative risk,
mean difference, hazard ratios etc
b. ‘What are the results?’ express the magnitude of the result in a quantitative way (eg (RR
0.29; 95% CI 0.04 to 2.27)
c. “How precise is the treatment effect?” discuss the precision (eg very precise because the
confidence interval was very narrow and did not cross the line of no effect)
d. “What is the magnitude of the treatment effect”: (e.g. Is the effect big? Will it have a big
impact on the patient? Or perhaps the treatment made no difference).
e. “Were there sufficient numbers or participants?”. See if a power calculation was done

Specifically for systematic reviews: For the section:

f. “Were the individual studies rated or appraised and reported?”:
This is referring to the appraisal of the included studies for any potential risk of biases. This
should be in the method section, not at the GRADE analysis) If done, what were the
authors’s findings? Were they generally of low risk of bias (for example there is a risk of bias
summary table or graph which is mainly green indicating low risk of bias in most of the
included studies).
g. “Were the results consistent from study to study?”
This refers to whether the included studies were all similar. An example of your answer
could be: “No, because the included studies were all very different and the I2 value was
high”)

7. Application:
In 2 or 3 sentences discuss how the above would apply to the patient in your neonatal write-up.
Updated 1.6.23
 Look at whether the authors use statements such as “uncertain”, “may” help or “probably” helps.
Taking into account the condition of the patient, the cost, the availability of the treatment, the
similarity of your patient with the patients in the review, and what the parents preference might be
how might the findings apply to the patient?

The following headings should be included in your report:

1. General Question
2. PICO
3. Search terms and results of search
4. Article selected and brief description of the article
5. Critical appraisal of the article (Use the appropriate worksheet available in Moodle)
6. Application

Marking rubric indicating maximum marks for each level

Level 1 (25%) 2 (50% ) 3 (75% ) 4 (100%)
General Question Max 2 Max 5 Max 7 Max 10
(10%) Question was Question was Question selected could
formulated after formulated after Question selected make a difference to the
the article was the article was could make a baby in the neonatal
identified and had identified and did difference to the writeup. Justification
no relevance to not relate to the baby in the given as to why this
the baby in the baby in the neonatal writeup. question is important to
neonatal writeup neonatal writeup the baby.

PICO 2 5 7 10
(10%) Most elements of Some elements of All elements of All elements of PICO
PICO incorrect OR PICO incorrect PICO correct correct AND
It is clear that Student reformatted the
student general question above
developed PICO into a PICO question
based on paper
selected

Search terms and 2 5 7 10

results of search Did not use terms Used terms from Used terms from Excellent search
(10%) from the PICO to PICO. PICO. Appropriate strategy. Search strategy
search an Inappropriate database used. displayed with relevant
appropriate database used. Search duplicable. articles in the search
database. Search Search results results.
results not displaying huge Search duplicable.
displayed. numbers of
inappropriate hits.
Search not able to Search not able to
be duplicated be duplicated

Updated 1.6.23
 Summary of 2 5 7 10
article Summary copied A fair summary A concise As per Level 3, and
(10%) off the abstract which gives an summary of 2-4 written in a way that
idea of the study sentences stating clearly justifies why the
design, the the study design, article meets your PICO
patients, the the patients, the
intervention and intervention and
the main result the main result

Critical appraisal 12 25 35 50
of article Appraisal done Appraisal done Appraisal done As per level 3 and
(50%) using the using the using the demonstrates a good
appropriate appropriate appropriate understanding of how to
critical appraisal critical appraisal critical appraisal appraise an article, with
worksheet. Most worksheet. Some worksheet. all the sections in the
of the sections in of the sections in Most of the worksheet done well
the appraisal the appraisal sections in the
sheet incorrectly sheet incorrectly appraisal sheet
answered, answered, correctly
demonstrating demonstrating answered.
poor poor For the section
understanding of understanding of ‘What are the
how to appraise how to appraise results?’ able to
the article the article express the
magnitude of the
result in a
quantitative way
and discuss the
precision of the
result.
Application 2 5 7 10
(10%) Attempts to Attempts to As per level 2, As per Level 3, with
discuss how this discuss how this with better consideration given to
evidence would evidence would correlation to the the certainty of the
apply to the apply to the initial question results and use of other
patient in the patient in the asked and evidence from other
neonatal write-up neonatal write-up patient’s sources.
but may have with correct condition
wrong interpretation of
interpretation of the results
the results

Updated 1.6.23