Newborn Exam HPI
Address parental concerns. Discuss feeding: Breastfeeding versus formula feeding? Quantity and frequency of feeds Discuss elimination and voiding patterns: How many wet diapers in 24 hours? How many soiled diapers in 24 hours? Discuss sleep patterns and positions. PMH: Prenatal history: Document the number of prenatal care months. Any exposure to alcohol, tobacco, medications, or drugs? Any medical problems during pregnancy such as thyroid disease, anemia, infec-tions, gestational diabetes, eclampsia, or bleeding? Birth history: Was the delivery vaginal or cesarean? Forceps or vacuum used? Did the baby need to be resuscitated? Hospitalization: Did the baby go home with mother or stay for observation? Immunizations: Did the baby receive the hepatitis B vaccine in the hospital? PSH: Any special procedures: If male, was a circumcision performed? Allergies: Any known drug allergies? Medications: Is the baby taking any prescribed or over-the-counter medications? FMH: Review family medical problems, congenital illnesses, or developmental delays. SH: Who are the infant's primary caretaker(s)? Number and age of siblings? Any exposure to second-hand smoke? Are there financial resources to provide for the child? Are both parents living together in the same household? Number and age of siblings? Any exposure to second-hand smoke? Are there financial resources to provide for the child? Are both parents living together in the same household?
Result - Copy and paste this output:
Sandbox Metrics: Structured Data Index 0, 212 boilerplate words
More SOAPnotes by this Author:
Send Feedback for this SOAPnote