Newborn Admission Note
[textarea columns=80 rows=50 default="HISTORY OF PRESENT ILLNESS: #1 Newborn infant admission note ***Was present at/Was not present at/Called to*** the ***spontaneous vaginal/C-section/vacuum assisted vaginal/forceps assisted vaginal/precipitous vaginal*** delivery of this ***gestational age*** infant ***female/male*** to a ***mom’s age*** year old G*** P*** now P***. Mother’s blood type ***. Mother’s Rubella status ***RI/RNI/R unknown***, ***HBV-/HBV+/HBV unknown***, ***HIV-/HIV+/HIV unknown***, ***GBS-/GBS+/GBS unknown*** Pregnancy complications: ***uncomplicated/GBS positive/GBS Unknown/Hepatitis B surface antigen positive/< 37 weeks gestation/Meconium-stained amniotic fluid/PIH/Pre-eclampsia/Diabetes/Gestational diabetes/Multiple gestation/Breech presentation/Chorioamnionitis*** Delivery complications: ***Uncomplicated/Breech presentation/Chorioamnionitis/Failure to progress/Meconium/Non-reassuring fetal heart rate tracings/Nuchal cord/Shoulder dystocia*** Maternal medications prior to delivery included: ***Glyburide/opiods/betamethasone/antibiotics*** At birth, the infant ***gave spontaneous breaths, cried, and was warmed, dried, and stimulated/was resuscitated***. Resuscitation measures included: ***Bulb suctioning and tactile stimulation/Blow by oxygen for *** minutes/Positive pressure ventilation for *** minutes/Chest compressions for *** minutes/Intubation/IV fluids/medications***. Apgar scores were *** at 1 minute, *** at 5 minutes. Labs drawn: ***CBC/Blood culture/Blood gas ***pH, pCO2, pO2, HCO, base excess***/blood glucose Imaging: ***Chest x-ray/Abdominal x-ray*** EXAMINATION: Vitals: ***height/weight/head circumference/birth temperature*** Skin: Normal turgor and without lesions. Head: Normocephalic with age appropriate fontanelles. ENT: Palate is complete. Eyes: Red reflex present bilaterally. Pupils equally round and reactive to light. Lymph Nodes: No significant lymphadenopathy. Thyroid: No thyromegaly; trachea midline without masses. Breasts: Without lesions or drainage. Peripheral Vessels: Normal pulses and perfusion. Heart: Regular rate and rhythm; normal S1 and S2; no murmurs, gallops, or rubs. Lungs: Unlabored respirations; symmetric chest expansion; clear breath sounds. Abdomen: Soft, without organomegaly. Bowel sounds normal. Nontender without rebound. No masses palpable. No distention. Genitalia: ***Normal male external genitalia; testes descended bilaterally; no hernia./Normal female external genitalia.*** Tanner Stage: I. Spine: Straight with no lesions. Joints: Hips with full range-of-motion; negative Barlow and Ortolani. Extremities: No clubbing, cyanosis, or edema. Normal upper and lower extremities. Mental Status: Alert, oriented, in no distress. Appropriate for age. Neuro: Normal reflexes; normal tone; no focal deficits appreciated. Appropriate for age. ASSESSMENT/PLAN: #1 Newborn ***Premature/Term*** ***Female/Male*** -Admit to Newborn Nursery for routine newborn cares -Hearing Screen, state newborn screen prior to discharge -Hepatitis B vaccine per nursing protocol -Feeds ad lib"]
There are 0 form elements.
Result - Copy and paste this output:
Sandbox Metrics: Structured Data Index 0, 394 boilerplate words
More SOAPnotes by this Author:
Send Feedback for this SOAPnote
You must be logged in to post a comment.