Neonatology Consult
 

• Requesting physician
• Date and time
• Asked to see this ___ year old, G__ P__ab__ female at __ weeks getation dates due to ____
• Other maternal conditions

I spoke with mother at bedside and updated her regarding the following concerns:

• Potential rate of survival at this gestational age if no congenital anomalies approximately __%
• Potential for morbidity including but not limited to the following problems
• Risk of neurological problems including:
• __intraventricular hemorrhage
• __developmental delay
• __cerebral palsy
• Risk for eye problems:
• __ need for glasses
• __ potential risk of blindness
• __ or eye surgery
• Risk of lung disease:
• __ need for respiratory support with mechanical ventilators
• __ chronic lung disease, including need for long term supplemental oxygen
• Risk of heart problems:
• __ including risk of patent ductus arteriosus requiring medication or surgery
• Risk of feeding problems:
• __ including need for gavage feedings
• __ inability to tolerate feedings
• __ risk for necrotizing enterocolitis which may include need for surgery and loss of bowel
• __ need for long term IV's or central lines for IV nutrition
• Risk for infection
• __ due to maternal infection, prematurity and complications of invasive procedures
• __ need for probably antibiotic treatment for one or more courses
• Other problems as specified: _____

Mother understood the problems and agree to the plan for the infant which includes:

• __ full resuscitation
• __ treament in the NICU with whatever treatment is indicated
• __ full care unless responsive to treatment or condition non-viable
• __ comfort care only

Other family members present: _____
Interpreter: _____

Signature:_____