Newborn Discharge Summary Form

This convenient 3-ply form summarizes the condition and care of the infant prior to discharge and documents the health status of the infant upon discharge. "Memory joggers" help prevent errors of omission in charting and eliminate misinterpretation of handwriting. Key elements include:
• Medications
• Complications
• Lab Tests and Results
• Discharge Comments and Plan
• Follow-Up Care Instructions and Referrals

Ply one remains in the infant’s hospital chart; ply 2 is sent to the infant’s physician; ply 3 sent to mother’s physician.