AI Scribe for Neonatologists
Document NICU care, resuscitations, and premature infant management in seconds. PatientNotes captures ventilator settings, nutrition calculations, and generates comprehensive systems-based notes.
Documentation for Every NICU Encounter
From delivery room resuscitations to NICU discharge, PatientNotes handles all neonatology documentation needs
NICU Daily Progress Notes
Comprehensive systems-based documentation including respiratory, cardiovascular, fluids/nutrition, and developmental care.
Delivery Room Resuscitations
Detailed resuscitation notes with timeline, interventions, medications, and transition to NICU or well-baby nursery.
Admission H&Ps
Complete admission history and physicals for NICU admissions with maternal history, delivery details, and initial assessment.
Discharge Summaries
Comprehensive discharge documentation including hospital course, procedures, medications, feeding plan, and follow-up.
Procedure Notes
Documentation for line placements, intubations, lumbar punctures, and other NICU procedures with consent and complications.
Family Conferences
Meeting notes documenting discussions with families about diagnosis, prognosis, treatment plans, and goals of care.
Neonatology-Specific Features
Built for the unique documentation needs of neonatal intensive care
Gestational Age Tracking
Automatic calculation of gestational age, corrected age, and chronological age. Tracks development milestones relative to corrected age.
Ventilator Management
Document all ventilator modes and settings including conventional, high-frequency, and CPAP. Track weaning progress and blood gas trends.
Nutrition Calculations
Calculate fluid rates (mL/kg/day), caloric intake, TPN/lipid dosing, and feeding advancement for premature infants.
Growth Chart Integration
Track weight, length, and head circumference on premature infant growth curves. Monitor for appropriate growth velocity.
Systems-Based Notes
Organize daily progress notes by system: respiratory, cardiovascular, FEN, GI, hematology, infectious disease, neurology.
Resuscitation Timeline
Capture minute-by-minute resuscitation events including interventions, medications with exact times, and infant response.
Sample AI-Generated Neonatology Note
See how PatientNotes documents a NICU daily progress note
NICU DAILY PROGRESS NOTE Patient: Baby Boy Smith DOB: [Today's date] Gestational Age: 28 weeks 4 days Chronological Age: Day of Life 5 Corrected Gestational Age: 29 weeks 2 days Weight: 1180 grams (birth weight 1150g) RESPIRATORY: - Conventional ventilation: SIMV mode - Settings: PIP 18, PEEP 5, Rate 25, FiO2 0.35 - Blood gas (0600): pH 7.32, pCO2 48, pO2 62, HCO3 24, BE -2 - Breath sounds: Clear bilaterally, good air entry - Chest X-ray: Improving ground glass opacities, mild hyperinflation - Plan: Continue current settings. Wean FiO2 as tolerated. Repeat gas in AM. CARDIOVASCULAR: - Hemodynamically stable - Heart rate: 140-160 bpm, Blood pressure: 45/28 (MAP 34) - Capillary refill <2 seconds, pulses 2+ and equal - Small PDA identified on echo yesterday, currently hemodynamically insignificant - Plan: Monitor for signs of hemodynamic compromise. Repeat echo in 48 hours. FLUIDS/ELECTROLYTES/NUTRITION: - IV fluids: D10W with 2mEq/kg NaCl and 1mEq/kg KCl at 140 mL/kg/day - TPN initiated today with 3g/kg protein, lipids 2g/kg - Trophic feeds started: breast milk 1 mL/kg q3h via OGT - Urine output: 3.2 mL/kg/hr (adequate) - Lytes: Na 138, K 4.2, Cl 104, CO2 22 - Plan: Advance feeds by 1 mL/kg/feed if tolerating. Monitor residuals and abdominal exam. GASTROINTESTINAL: - Abdomen soft, non-distended - Bowel sounds present - Stools: Meconium, transitioning - No residuals with current feeds - Plan: Continue trophic feeds as above. HEMATOLOGY: - Hematocrit: 42% (Day 1) - Platelets: 210k - Plan: Recheck CBC in 3 days. INFECTIOUS DISEASE: - Blood culture: No growth at 48 hours (finalize at 5 days) - CBC: WBC 9.2, 42% neutrophils, 0% bands, no left shift - CRP: <0.5 mg/dL - Ampicillin and gentamicin Day 3 of 7 - Plan: Discontinue antibiotics at 48 hours if cultures remain negative. NEUROLOGY: - Head ultrasound (Day 3): Grade I IVH on left, no progression - Tone and activity appropriate for gestational age - Plan: Repeat head ultrasound weekly. Monitor for apnea/bradycardia. PLAN: 1. Continue respiratory support, wean as tolerated 2. Advance nutrition gradually 3. Monitor PDA clinically, repeat echo in 48 hours 4. Likely discontinue antibiotics tomorrow if cultures negative 5. Developmental care: minimize stimulation, clustering cares 6. Family update provided, parents at bedside today
Intelligent ICD-10 Suggestions
PatientNotes suggests the codes most commonly used in neonatology
P07.31Preterm newborn, gestational age 28-31 completed weeksP22.0Respiratory distress syndrome of newbornP29.30Patent ductus arteriosus of newbornP36.9Bacterial sepsis of newborn, unspecifiedP52.3Intraventricular (nontraumatic) hemorrhage, grade 3, of newbornP92.5Neonatal difficulty in feeding at breastP59.9Neonatal jaundice, unspecifiedP27.1Bronchopulmonary dysplasia originating in perinatal periodAI suggests relevant codes based on your documentation—review and select with one click.
Frequently Asked Questions
Can PatientNotes document complex NICU progress notes?
Yes. PatientNotes captures comprehensive NICU notes including ventilator settings, vital signs, lab values, feeding protocols, medications, and assessment/plan by system. The AI organizes information in the standard NICU format.
Does PatientNotes handle delivery room resuscitation documentation?
Yes. PatientNotes creates detailed resuscitation notes including gestational age, birth weight, APGAR scores, resuscitation steps performed, medications given with doses and times, and response to interventions.
How does PatientNotes track ventilator management?
PatientNotes documents ventilator mode, settings (PIP, PEEP, rate, FiO2), blood gas results, and ventilator changes. It tracks trends over time and helps monitor respiratory status progression.
Can PatientNotes document premature infant growth and nutrition?
Yes. PatientNotes tracks daily weights, feeding volumes, TPN/lipid doses, and growth parameters. It monitors nutritional advancement and calculates fluid/caloric intake for premature infants.
See More Patients, Document Less
Join neonatologists saving 2+ hours daily on documentation. PatientNotes handles the charting so you can focus on your patients.
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