Newborn Progress Note
[textarea name="variable_1" columns=80 rows=25 fillable="true"]SUBJECTIVE: Day of life ****** for this newborn. Born by ***vaginal/vacuum assisted vaginal/forceps assisted vaginal/C-section*** delivery at ***time and date*** at ***gestational age*** weeks to a ***mothers age*** year old G****** now P****** mother. Pregnancy was ***uncomplicated/complicated by *** Mother is blood type ******, Hepatitis B ***negative/positive/unknown*** HIV ***negative/positive/unknown***, and was found to be GBS ***negative/positive/unknown*** Baby is feeding well by ***breast/bottle/bottle and breast*** No problems with urine or stooling pattern. OBJECTIVE: Skin: ***normal turgor and without lesions/Jaundice of face/Jaundice to nipple line/Jaundice to abdomen/Jaundice to thighs/Erythema toxicum*** Head: Normocephalic with age-appropriate fontanelles. ENT: Normal appearing external ears. Nose clear. Palate is complete. CV: Regular rate and rhythm. Normal S1 and S2. No murmurs, gallops, or rubs. No peripheral cyanosis or edema Lungs: Unlabored respirations. Symmetric chest expansion. Clear breath sounds. Abdomen: Soft, without organomegaly. Bowel sounds normal. No masses palpable. No distention. Genitalia: ***Normal male external genitalia. Testes descended bilaterally./Normal female external genitalia.*** Joints: Hips with full range of motion. Negative Barlow and Ortolani. ASSESSMENT/PLAN: #1 Newborn ***male/female*** -Continue normal newborn nursery cares and feeds ad lib -Hearing screen, state newborn screen, prior to discharge -Hepatitis B vaccine per nursing protocol[/textarea]
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