Paediatrician Template

Well Neonate 0-1 MO

A professional Paediatrician template for healthcare professionals.

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Specialty

Paediatrician

Used

75 times

Type

Note

Last edited

2/26/2025

Created by

Rajesh Sharma

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About this template

The Well Neonate 0-1 MO template is a comprehensive clinical documentation tool designed for paediatricians conducting routine check-ups for newborns aged 0 to 1 month. This template facilitates the recording of essential information such as birth history, nutrition, household safety, immunizations, and developmental milestones. It also includes sections for physical examination findings and anticipatory guidance, ensuring a thorough assessment of the neonate's health and development. Ideal for paediatricians, this template streamlines the documentation process, enhancing the efficiency and accuracy of neonatal care in clinical settings.

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PATIENT'S NAME: **JANE DOE** **DOS: _1 November 2024_** DOB: **10/01/2024** AGE: 1 month SEX: Female ACCOMPANIED by: Mother **SUBJECTIVE:** -History of Present Illness: BIRTH History: Baby was born at Ochsner Westbank Hospital. Baby was born at 39 weeks GA by NSVD and was discharged home on 10/05/2024. Mom G2,P1. Maternal labs unremarkable. Maternal hx and pregnancy unremarkable. Baby passed CCHD and passed hearing screen. Baby received Hep B immunization, Vit K and erythromycin. NUTRITION: Birth weight was 7 lbs 2 oz. Weight today is 5% up from Birth Wt. Has been breast feeding. Baby is latching well and mom's breastmilk is in now, mom is comfortable with how feeds are going. In the last 24 hours, baby had adequate wet diapers and stools. Household/Safety: Lives with: Mother and Father Baby is sleeping in own crib on back. Baby has a rear facing car seat in the back seat of the car. Immunizations: - Up to date Growth and Development: - Normal developmental screening results Social History: - Stable living situation - Safe home environment Family History: - No significant family history **OBJECTIVE:** Growth Parameters:- Wt: 8 lbs (50th percentile), Ht: 20 inches (50th percentile) - Vital Signs: Temperature: 98.6°F, Pulse: 120 bpm, Respiratory rate: 30 breaths/min - PHYSICAL EXAMINATION: - General Appearance: Active, Alert, Pink, and Nontoxic - Eyes: Normal eyes, No redness - Nose: Normal - Ears: Normal TM with good LR - Throat: No redness or ulcers - Chest/Lungs: Equal breath sounds bilaterally, no retractions, No wheezing or rales - Cardiovascular: NSR, Normal S1 and S2, No Murmur heard - Abdomen: Soft, Non tender, No HSM - Skin: No rashes - Musculoskeletal: Moving all Extremities well - CNS: Normal tone and reflexes *SCREENINGS: - Newborn Blood screen, PKU: Normal - Subjective Vision screening: Normal - Hearing screening result: Responds to voices - Safety screening - Discussed **ASSESSMENT*: - Well child exam normal - Growth assessment: Normal - Developmental screening result: Normal **PLAN*: - Vaccinations administered: None due today - *ANTICIPATORY GUIDANCE: - Language development recommendations: Encourage talking and reading - Car seat recommendations: Discussed - Safety recommendations: Discussed - Sleep recommendations: Back to Sleep - Nutrition recommendations: Feeds on demand - Follow-up recommendations: 2 wks -Signed: DR. RAJESH K. SHARMA, MD,