🩺 Doctor Daily Entry
NICU System-Based Clinical Notes
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📋 Patient Identification
🎤 System-Based Clinical Notes
Click 🎤 to voice-dictate or type directly. All sections auto-save together.
Current Problems (active diagnoses)
Active diagnoses with ICD-11 codes. Use ↓ to resolve a problem
(moves to Previous). Voice-dictate or search to add.
Previous Problems (resolved / inactive)
Resolved or inactive problems. Use ↑ to reactivate (moves back
to Current).
Respiratory System
O₂ requirement, ventilator mode/settings, FiO₂, SpO₂,
apnea/bradycardia, chest exam, ABG results.
Cardiovascular System
HR, BP, perfusion, CRT, pulses, murmurs, echo findings,
inotropes.
GI System / Feeds
Feed type (EBM/formula), volume, frequency, tolerance, abdomen
exam, stools, TPN, liver function.
Central Nervous System
Activity, tone, reflexes, seizures, fontanelle, cranial USS/MRI
findings.
Sepsis / Infection
Sepsis screen, CRP, blood culture, PCT, antibiotics (drug,
day#), plan to stop/change.
Fluids & Electrolytes
Urine output (ml/kg/hr), fluid balance (I/O), IV fluids
(ml/kg/day), Na, K, Ca, glucose, renal function.
Medications (SNOMED CT)
Current medications, doses, frequency. Search uses SNOMED CT
Indian Extension (CDCI).
Lab Results (LOINC)
Blood tests, cultures, ABG. Search uses LOINC codes for
laboratory tests.
Imaging
X-ray, USS cranial, echocardiography, MRI findings and reports.
Invasive Lines
UVC/UAC (depth, day#), PICC line, peripheral IV, ET tube (size,
depth), chest drain, plan for removal.
Management Plan
Today's plan, medication changes, tests to order,
consultations, milestones.
Notes / Family Communication
Family updates, counselling, concerns, important events,
mother's condition.
Weekly Growth Measurements
Head circumference, length, and weight — recorded weekly on the configured day.
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