Daily Progress Notes

Daily Progress Notes are the up-to-the-minute daily information source on all NICU patients. Crib Notes™ provides both detailed and summary patient overviews. With a few clicks, it can access the full library of previous notes and information already in the system. As a result, input of a typical Daily Progress Note on a stable premature infant takes just minutes. The layout of the Progress Notes and the problem areas within the Progress Notes make following patient clinical trends simple.

User defined permissions allow only approved clinicians to add information directly into the page, while all caregivers can view the data.

Information is organized by clinical problem-area, a method widely recognized by neonatologists as covering the entire care spectrum. Within these sections and where appropriate, flowsheet data from nursing is automatically pulled in and summarized into complete sentences to create the Objective section of a SOAP note. Notes can be completed with minimal editing by checking default boxes and selecting from pull-down lists.

Structured diagnoses and other discreet data elements can be entered at the same time as notes are written to further streamline the data collection process.

Crib Notes™ autopopulates relevant information from the nursing flow sheets, interfaced patient monitoring devices and other IT clinical systems. This includes health care maintenance (also known as fluid, lytes, nutrition) lab results, respiratory settings and measurements, hematology lab results, blood product transfusions, bilirubins and more. The depth and variety of Crib Notes™' data collection is unprecedented for a NICU EMR system.

This data automatically gives clinicians all the objective information needed to assess a patient problem and determine the best intervention. Radiology and other dictated reports are also available at the click of a button.

Clinicians note information about consultations with optional patient weekly summaries. Crib Notes™ allows for one-click navigation to full Nursing Flowsheets or summary data.

Progress Notes can be viewed by all care providers with user access, including medical and surgical consultants, OTs, PTs, developmentalists, and social workers. The readability and accessibility of these notes contributes to better patient care, collaboration and communication in the NICU. Progress Notes functionality concludes with the Discharge Summary, which requires only a few button clicks to complete.

Crib Notes™ Discharge Summary documentation automatically pulls all relevant Clinical Summary information, which clinicians update periodically as part of their daily progress notes. The result is a complete, up-to-date summary in seconds, without transcription costs. Crib Notes™ even automates report faxing to the patient’s pediatrician and printing for parent distribution.

Progress Note