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Discipline

: Paediatrics

Sub Discipline

: Neonatology

Document Title

: Newborn Examination and Screening Checklist

Unit

Header / Title

Place Of Examination

Mother's Ic

Race

MATERNAL HISTORY

Mother's Age

Gravida

Para

Abortion

Living Children

Blood Type

Vdrl / Rpr

Specify Titre

TPHA

Hbsag

Hvs Swab Culture

HIV

Hiv Rapid Test

Other Significant Maternal History

LMP

EDD

Pog

By Dates

Weeks Days

By Ultrasound

Weeks Days

Antenatal Complication

Labor

Delivery

BABY'S RECORD

Baby's Sex

Anthropometry Measurement

Apgar Score

Resuscitation And Stabilisation Comments

Cord Blood Gas

PHYSICAL EXAMINATION

Exam Date and Time

Gestational Age

By Dates

Weeks Days

By Ultrasound

Weeks Days

By Ballard Score

Weeks

Vital Signs

Color

Pink

Cyanosis peripheral

Cyanosis central

Jaundice

Pallor

Plethoric

Head And Neck

Facies

NormalDysmorphic

Head Shape

NormalAbnormal

Fontanelle

NormalBulgingDepressed

Sutures

NormalAbnormal

Head Swelling

None

Caput succedaneum

Cephalohematoma

Subaponeurotic Hemorrhage

Others, specify

Eyes

Eye Discharge

YesNo

Cornea

ClearCloudy

Conjunctival Haemorrhage

YesNo

Red Eye Reflex

NormalAbnormal

Ear

NormalAbnormal

Nose

NormalAbnormal

Mouth

NormalAbnormal

Cleft Lip

YesNo

Cleft Palate

YesNo

Neck

NormalAbnormal

Cardiovascular System

Heart Rate

Pulse Volume

Good WeakNot felt

Capillary Refilling Time

<= 2 secs> 2 secs

Femoral Pulse

PresentAbsent

Apex Beat

Right chestLeft chestNot felt

Heart Sounds

Heart Murmur

YesNo

Pulse Oxymetry Screening

Preductal Right Hand SPO2 (%)

Postductal Right Leg SPO2 (%)

Postductal Left Leg SPO2 (%)

Respiratory System

Respiratory Rate

Stridor

YesNo

Nasal Flaring

YesNo

Grunting

YesNo

Respiratory Effort

GoodPoor

Chest Recession

YesNo

Chest

NormalPectus carinatumPectus excavatum Other Abnormality

Lungs

Breath sounds

Additional sounds

Abdomen

Shape

NormalDistendedScaphoid

Liver

Not PalpablePalpable

Spleen

Not PalpablePalpable

Kidney

Not ballotableBallotable

Bowel Sounds

PresentAbsent

Umbilicus

NormalAbnormalUmbilical Artery

Single umbilical arteryTwo Umbilical Artery

Anus

PatentImperforate

Fistula

NoYes, specify

Genitalia

MaleFemaleIndeterminate

Common Textbox

Musculoskeletal

Spine

NormalAbnormal, specify

Common Textbox

Upper Limbs

NormalAbnormal, specify

Lower Limbs

NormalAbnormal, specify

Hips

Ortolani

NegativePositive

Right

Left

Bilateral

Barlow

NegativePositive

Right

Left

Bilateral

Ctev

YesNo

Neurological

Posture

FlexedLimpOthers

Activity

ActiveLethargic Comatose

Cry

Tone

NormalHypotonicHypertonic

Movement

NormalAsymmetrical MovementNone

Sucking Reflex

NormalWeakNone

Moro Reflex

CompleteIncompleteAsymmetricalAbsent

Grasp Reflex

PresentAbsent

Skin

NormalOther Abnormality

Other Abnormality

DIAGNOSIS

Diagnosis

MANAGEMENT

Orders

Referral

Outgoing Referrals

Comments

Plan

SIGNATURES

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