Transitioning Newborns from NICU to Home: Family Information Packet

Appendix C. NICU Needs Assessment





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: Transitioning Newborns from NICU to Home: Family Information Packet: Appendix C. NICU Needs Assessment. December 2013. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/systems/hospital/nicu_toolkit/nicu-packet-apc.html