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Neonatal Clerking Note

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Unit

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Header / Title

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Referring Unit/Hospital

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Baby's Sex

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Place Of Birth

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Date And Time Of Birth

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Home Address

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Date And Time Of Admission

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MATERNAL HISTORY

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Mother's Name

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Mother's Ic

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Mother's Age

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Mother's Ethnic

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Gravida

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Para

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Abortion

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Living Children

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Blood Type

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Rhesus

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Vdrl / Rpr

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Hbsag

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HIV

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Medical History

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Surgical History

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Significant Family History

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Consanguinity

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Social History

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PAST OBSTETRIC HISTORY

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PRESENT PREGNANCY

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LMP

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EDD

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Gest. Age By Dates

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Weeks

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Days

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Multiplicity

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Antenatal Care

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Place /s

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Ultrasound

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A) First

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B) Others

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C) REDD (If Any)

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Complications

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Maternal Diabetes (Including Gestational Diabetes)

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Maternal Hypertension, Chronic Pregnancy Included

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Maternal Eclampsia

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Maternal Chorioamnionitis

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Maternal Anaemia

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Maternal Uti

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LABOUR AND DELIVERY

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Maternal Admission Date and Time

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Referral from Other Hospital / Clinic

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Antenatal Steroid

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Highest Temperature >= 38°C

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Maternal Abruption Placenta

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Maternal Bleeding Placenta Praevia

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Fbc

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HB, WBC, PLT

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Hvs Swab

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Crp

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Intrapartum Antibiotics

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Comments

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LABOUR AND DELIVERY RECORD

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Onset Of Labour

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Rupture Of Membranes

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Medication(S) In Labour

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Second Stage (Duration)

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Fetal Distress

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Infant Delivery

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Date And Time

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Comments

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Infant Delivery

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Placenta

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Weight (g)

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Abnormalities

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Comments

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RECORD RESUSCITATION AND STABILIZATION

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Apgar Score

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If Apgar Score > 20 minutes

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Resuscitation

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If No Spontaneous Respiration At Delivery, Time To Regular Respiration (Minutes)

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Resuscitation and Stabilization / Other Comments

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Vitamin k

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Hepatitis B

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Hepatitis B

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PHYSICAL EXAMINATION

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Exam Date and Time

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Current Age

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Gestational Age At Birth

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By Dates

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By Ultrasound

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By Ballard Score (Weeks)

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Anthropometric

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Temperature °C

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Colour

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Capillary Blood Sugar(mmol/L)(If Performed)

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Head And Neck

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Heent (Head, Eyes, Ears, Nose And Throat)

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All Normal

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Facies

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Head Shape

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Ant. Fontanelle

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Post. Fontanelle

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Sutures

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Eyes (G)

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Red Eye Reflex

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Ears

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Nares

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Mouth

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Palate

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Neck

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Other Abnormality

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Cardiovascular System

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Heart Rate (beats/mn)

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Blood Pressure

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Systolic (mmHg)

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Diastolic (mmHg)

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Mean Bp (mmHg)

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Capillary Refill Time (Sec)

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Pulse Volume

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Femoral Pulse

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Apex Beat Location

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Heart Sounds

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Heart Murmur

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Other Abnormality

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Respiratory

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Intubated

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NCPAP

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Respiratory Rate (breaths/min)

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O2 Saturation (%)

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Condition

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Respiratory Effort

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Nasal Flaring

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Grunting

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Stridor

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Recession

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Chest

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Lungs - Breath Sounds

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Other Abnormality

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Abdomen

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Shape / Skin

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Liver

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Spleen

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Kidney

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Umbilicus

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Umbilical Artery

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Bowel Sounds

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Anus

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Other Abnormality

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Genitalia

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Testis

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Hypospadias

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Hydrocele

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Enlarged Clitoris

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Labial Adhesions

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Impeforate Hymen

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Vaginal Bleed

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Indeterminate

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Other Abnormality

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Musculoskeletal

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Spine

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Upper Limbs

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Lower Limbs

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Developmental Dysplasia Of Hips

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Ctev

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Neurological

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Posture

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Activity

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Cry

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Tone

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Movement

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Sucking Reflex

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Moro's Reflex

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Grasp Reflex

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Other Abnormality

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Skin

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Other Abnormality

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Other Comments On Physical Examination

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DIAGNOSIS

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MANAGEMENT

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Orders

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Others

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To do SNAPPE II Score (after 12 hours)

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Referral

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Outgoing Referrals

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Comments

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Plan

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SIGNATURES

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