I used a work sheet like Gompers described, also had sections (5x8, front and back preprinted) for maternal/social history, 'demographics' like date of birth, birth weight, gestational age, common dx's I could circle, other past history events, surgery, etc. The front of the page was the current info, vent settings, the hour schedule, labs pending or due, today's date, todays conceptual age, IV's, feedings-what, how, how often-, d/c plans/teaching.
Eventually, the unit printed my form and pads of them were available in the unit. It's not hard to develop your own. Some nurses used a spiral notebook. Then, if you went back to the same pt. several days later, you had a lot of the info already. Made it easier for evaluations, too. Just BE SURE to black out the name to maintain confidentiality.