322-0830 NEWBORN ADMIT FORM rev 07-10

NEWBORN/INFANTADMIT/DISCHARGE RECORDBirth Date: __________________________ Time of Delivery: _________________ Sex: Male / FemaleMATERNAL HISTORY: Age: __________ Gravida: ________ Para: ________ Ab: ________ Gestation (wks): __________Maternal Blood Type: A / B / AB / O / + / – Abs: + – GBS: + – Hep B: + –Rubella: + – VDRL/RPR: + – CT + – GC + – HIV + –Prenatal Problems: ______________________________________________________________________________________Social History: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Family History: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________DELIVERY: AROM / SROM ________ hours prior to delivery for ____________________ fluid.Delivery via: ________________________________ Medications:________________________________________________Complications of delivery: ________________________________________________________________________________APGARS: 1 Minute _______________ 5 Minutes _______________ 10 Minutes _______________Resuscitation: __________________________________________________________________________________________ADMISSION PHYSICAL EXAM: Birth Weight: __________ (g / lb)Length: ____________ (cm / in) Head Circum: ____________ (cm / in)Gen: nutrition status good.HEENT: anterior fontanelle soft, eyes normal, __________ bilateral red reflexes, ears normal, palate intact,mucosa moist and pink.Neck: no masses.Resp: normal AP chest diameter and expansion. No asymmetry; no respiratory distress; clear auscultation.CV: normal S1 and S2, without murmur.Abd: No masses, without hepatosplenomegaly, normal bowel sounds, umbilical cord normal.Genitalia: normal _______________ female _______________ male, testes descended.Extremities: warm and without edema, no cyanosis; _______________ hips with negative Ortolani and Barlow.Skin: no lesionsNeuro: normal behavior for age and condition, no abnormal movements, normal strength and tone.Other findings: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ADMIT DIAGNOSES: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ADMIT PLAN: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ADMITTING MD/NNP: __________________________________________________ DATE/TIME: __________________________FORM 322-0830 Rev. 7/10WHITE - MEDICAL RECORDYELLOW - PHYSICIAN COPYNEWBORN/INFANT ADMIT/DISCHARGE RECORD

NEWBORN/INFANTADMIT/DISCHARGE RECORDFINAL PROGRESS NOTE: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Jaundice: Yes / No Course: __________________________________________________________________________________Peak Bilirubin: ____________ Date: ___________________ Discharge Bilirubin: ____________ Date: ______________________Infant Blood Type: A / B / AB / O / + / – Coombs Direct: + / – Indirect: + / – G6PD: _____________Newborn Screen: Yes NoDrawn < 24h of age: Yes NoHearing Screen: Yes No Result if known: pass / inconclusive Circumcision: ______________________Hepatitis B vaccine: Yes No Erythromycin eye oint: Yes No Vit K: Yes NoDISCHARGE PHYSICAL EXAM: Discharge exam is also Admission Exam: Discharge Weight: ____________ (g / lb)Gen: nutrition status good.HEENT: anterior fontanelle soft, eyes normal, __________ bilateral red reflexes, ears normal, palate intact,mucosa moist and pink.Neck: no masses.Resp: normal AP chest diameter and expansion. No asymmetry; no respiratory distress; clear auscultation.CV: normal S1 and S2, without murmur.Abd: No masses, without hepatosplenomegaly, normal bowel sounds, umbilical cord normal.Genitalia: normal _______________ female _______________ male, testes descended.Extremities: warm and without edema, no cyanosis; _______________ hips with negative Ortolani and Barlow.Skin: no lesionsNeuro: normal behavior for age and condition, no abnormal movements, normal strength and tone.Other findings: ____________________________________________________________________________________________________________________________________________________________________________________________________________DISCHARGE DIAGNOSES: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________POSTNATAL COURSE/CONDITION AT DISCHARGE: Normal NewbornLABS:DISCHARGE INSTRUCTIONS:DISCHARGE TO: Parents Other: __________________________________________________________________________FOLLOW UP: With: ________________________________________________ , MD Date / Time: __________________________DISCHARGING MD OR NNP: _______________________________________ DATE/ TIME: ______________________________ Discharge day services >30 minFAX TO: ________________________________________ FAX #: _________________________________ PAGES: ____________This communication is intended solely for the individual or entity to which it is addressed, and may contain information thatis confidential and/or prohibited from disclosure. If the reader of this communication is not the intended recipient, do notreview, distribute or copy this communication. If you have received this in error, please notify us immediately by telephoneand return the original to us at our expense to the address above via the U.S. Postal Service. Thank you.FORM 322-0830 Rev. 7/10WHITE - MEDICAL RECORDYELLOW - PHYSICIAN COPY

NEWBORN/INFANTADMIT/DISCHARGE RECORDFINAL PROGRESS NOTE: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Jaundice: Yes / No Course: __________________________________________________________________________________Peak Bilirubin: ____________ Date: ___________________ Discharge Bilirubin: ____________ Date: ______________________Infant Blood Type: A / B / AB / O / + / – Coombs Direct: + / – Indirect: + / – G6PD: _____________Newborn Screen: Yes NoDrawn < 24h of age: Yes NoHearing Screen: Yes No Result if known: pass / inconclusive Circumcision: ______________________Hepatitis B vaccine: Yes No Erythromycin eye oint: Yes No Vit K: Yes NoDISCHARGE PHYSICAL EXAM: Discharge exam is also Admission Exam: Discharge Weight: ____________ (g / lb)Gen: nutrition status good.HEENT: anterior fontanelle soft, eyes normal, __________ bilateral red reflexes, ears normal, palate intact,mucosa moist and pink.Neck: no masses.Resp: normal AP chest diameter and expansion. No asymmetry; no respiratory distress; clear auscultation.CV: normal S1 and S2, without murmur.Abd: No masses, without hepatosplenomegaly, normal bowel sounds, umbilical cord normal.Genitalia: normal _______________ female _______________ male, testes descended.Extremities: warm and without edema, no cyanosis; _______________ hips with negative Ortolani and Barlow.Skin: no lesionsNeuro: normal behavior for age and condition, no abnormal movements, normal strength and tone.Other findings: ____________________________________________________________________________________________________________________________________________________________________________________________________________DISCHARGE DIAGNOSES: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________POSTNATAL COURSE/CONDITION AT DISCHARGE: Normal NewbornLABS:DISCHARGE INSTRUCTIONS:DISCHARGE TO: Parents Other: __________________________________________________________________________FOLLOW UP: With: ________________________________________________ , MD Date / Time: __________________________DISCHARGING MD OR NNP: _______________________________________ DATE/ TIME: ______________________________ Discharge day services >30 minFAX TO: ________________________________________ FAX #: _________________________________ PAGES: ____________This communication is intended solely for the individual or entity to which it is addressed, and may contain information thatis confidential and/or prohibited from disclosure. If the reader of this communication is not the intended recipient, do notreview, distribute or copy this communication. If you have received this in error, please notify us immediately by telephoneand return the original to us at our expense to the address above via the U.S. Postal Service. Thank you.FORM 322-0830 Rev. 7/10WHITE - MEDICAL RECORDYELLOW - PHYSICIAN COPY