Documentation Challenges in Neonatology

• Detailed systems-based documentation for critically ill neonates with rapid clinical changes
• Tracking daily ventilator settings, feeding advancements, and medication adjustments
• Documenting procedures like intubation, line placement, and surfactant administration
• Comprehensive discharge summaries with feeding plans, follow-up schedules, and family education
• Gestational age-specific documentation with corrected age calculations

Note Types for Neonatology

• Admission Notes

  Birth history, maternal factors, delivery details, and initial NICU assessment with Apgar documentation

• Daily Progress Notes

  Systems-based NICU progress with ventilator data, feeding status, and active problem tracking

• Discharge Summaries

  Comprehensive NICU discharge with hospital course, feeding plan, medications, and follow-up schedule

• Procedure Notes

  Intubation, umbilical line placement, lumbar puncture, and surfactant administration documentation

Key Features for Neonatology

• Systems-Based Notes

  Organized by respiratory, cardiovascular, GI, neuro, and metabolic systems

• Growth Tracking

  Daily weight trending with caloric intake and feeding advancement documentation

• Procedure Templates

  NICU-specific procedure documentation with timeout and consent capture

• Discharge Planning

  Structured discharge documentation with family teaching and follow-up coordination

Stats

• 90 min - Saved Per Shift
• 60 sec - Daily Notes
• 99% - Documentation Quality
• 12+ - NICU Note Types

Testimonial

NICU documentation is relentless — every vent change, every feeding adjustment, every lab result needs to be captured. Scribeable organizes it all by system and my notes are done before morning rounds end.