|
Term?
|
|
|
Pre-Term?
|
Gestation
|
|
|
Gestation +days
|
|
|
|
|
APGAR 1 minute
|
APGAR 5 minutes
|
|
APGAR 10 minutes
|
|
|
|
|
|
Birth Weight - Pounds
|
Birth Weight - Ounces
|
|
Discharge Weight - Pounds
|
Discharge Weight - Ounces
|
|
|
|
|
Hearing Screen
|
Pulse Ox Screen Normal?
|
|
|
|
|
Maternal Blood Type
|
Infant Blood Type
|
|
Direct Coombs
|
|
|
|
|
|
Bilirubin screening
|
Bilirubin Value
|
|
|
|
|
Hep B Vaccine Date
|
Neonatal Complications
• • •
|
|
Birth History Comments
|
|
|
Family History - Hearing
|
|
|
|
|
|
Nutrition
• • •
|
|
|
Breastfeeding minutes per feed
|
Breastfeeding Hours between feed
|
|
Problems breastfeeding
• • •
|
|
|
Lactation Consultant Recommended
|
|
|
Formula Type
|
Ounces per Feeding
|
|
Vitamins?
|
|
|
Elimination
• • •
|
Elimination Comments
|
|
|
|
|
Development - Social/Emotional
• • •
|
Development - Cognitive
• • •
|
|
Development - Communicative
• • •
|
Development - Physical
• • •
|
|
|
|
|
Anticip. Guidance - Newborn Tran
• • •
|
Anticip. Guidance - Newborn Care
• • •
|
|
Anticip. Guidance - Nutrition
• • •
|
Anticip. Guidance - Parental Wel
• • •
|
|
|
|
|
Vaccines Discussed/VIS Given
|
|
|
|
|
|
Additional Information
|
|
