NICU – Infant’s Medical Chart

Infant’s Medical Chart in the NICU

Every infant in the NICU has their own medical chart. This includes:

  • Graphical information (Address, parents, insurance, etc.)
  • Consents
  • Doctor’s Orders
  • Progress Notes
  • Radiology Reports
  • Cardiology Reports
  • Social Work Consultations
  • Physical Therapy and Occupational Therapy Reports
  • Nutritional Information
  • Nurse’s Notes
  • Discharge Paperwork
  • Medication Records
  • Family Paperwork
  • Lab Results

All of these are stored in a computer under a computerized medical chart, or at a bedside hospital chart. Many hospitals now use both.

If a parent wishes to view their baby’s chart, a doctor or practitioner is usually required to be present. Medical charts are very intricate and complex, and even the smartest parent will need some form of explanation to questions they might have.

If a parent wishes to acquire a copy of their infant’s chart, permission must come through the Health Information Department, also referred to as Medical Records. The NICU itself, in most cases, cannot consent to copying a chart due to legal liabilities.  They must pass that task on to medical records.