Transitioning Newborns from NICU to Home

Appendix C. NICU Needs Assessent

Infant's Name:

 

Date of Birth:

 

ID#:

 

Male

 

Female

 

Bed#:

 

Caregiver's Contact #:

 

Address:

 

Pediatrician Name and Number:

 

Birthweight

 

Current Weight

 

Primary Diagnosis

 

Newborn Blood Screening

Date:__________________________
 

Newborn Blood Screening Results

 

Immunizations Current?

  • No
  • Yes
RSV Prophylaxis Given?

  • No
  • Yes    Date: _______________________
Feeding:

  • Breast milk
  • Formula
Tobacco Use In Home?

  • No
  • Yes
Social Worker Referral Needed?

  • No
  • Yes
Transportation Needs?

  • No
  • Yes
Car Seat?

  • No
  • Yes
Car Seat Education?

  • No
  • Yes    Date: ________________________
Car Seat Test?

  • No
  • Yes    Date: ______________________
CPR Education?

  • No
  • Yes    Date: _________________________

 

 

 

 

Page last reviewed December 2013
Internet Citation: Appendix C. NICU Needs Assessent. December 2013. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/systems/hospital/nicu_toolkit/nicu-packet-apc.html