OT NICU Evaluation Form

The beginning of week 6 is upon us!  Time is flying and I am loving every bit of information I am learning in the NICU.

At the hospital I am completing my rotation at, when OT gets a consult from the medical team to evaluate and treat an infant in the NICU, we first complete a thorough chart review to gain as much information as we can before seeing the baby.  This is a way to be more prepared upon entering and determine what further information we need to gather throughout our session.

I have created a document that allows us to put all of our information in one place throughout the infant's hospital stay.  This evaluation form allows us to stay organized and best treat each baby and their families.  We also document all of our treatment sessions electronically.  This form is a way to keep up to date on our caseload and easily look for a baby's information within our clipboard or binder.

Name: Bay/Room # Date of Evaluation: GA: Reflexes: Palmar Grasp _______R   _______L Plantar Grasp _______R  _______L Scarf Sign __________	Mother’s Name: Age: Father’s Name: Age: Sibling______________Age__________ Sibling______________Age__________ Sibling______________Age__________ Sibling______________Age__________ Family Availability:
Infant Birth History DOB: GA at Birth: Mod of Delivery: Apgars________1min __________5min Birthweight _________g Diagnosis Complications of birth:	Maternal History Grava________ Para_______ Prenatal care/complications: Labor & Delivery: Medications:
Respiratory Assistance:	Social History:
Current Medications: Sedatives:  Diuretics: Anticonvulsants: Steroids: Antibiotics:  Other:  Caffeine      Theophylline	Interventions Provided: Stress Cues Observed:
Current Feeding/Nutrition: Time____________ Type__________	Coping Skills:   Observed      Facilitated Tone:
Head Shape Observations: Positioning devices provided/used:         Isolette    or    Crib