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Discipline

: Paediatrics

Sub Discipline

: Neonatology

Document Title

: Neonatal Clerking Note in Peripheral Wards

Unit

Header / Title

Reason For Referral

Review Date And Time

MATERNAL HISTORY

Mother's Name

Mother's Ic

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

Apgar Score

Please Update Method

If Apgar Score > 20 minutes

Resuscitation And Stabilisation Comments

PHYSICAL EXAMINATION

Exam Date/Time

Gestational Age

By Dates

Weeks Days

By Ultrasound

Weeks Days

By Ballard Score

Weeks

Anthropometry Measurement

Color

Pink

Cyanosis peripheral

Cyanosis central

Jaundice

Head And Neck

Facies

Normal

Head Shape

Abnormal, specify

Fontanelle

Bulging

Sutures

Abnormal, specify

Head Swelling, if present

None

Eyes

Eye Discharge

No

Cornea

Clear

Conjunctival Hemorhage

No

Red Eye Reflex

Abnormal, specify

Ear

Abnormal, specify

Nose

Abnormal, specify

Mouth

Abnormal, specify

Cleft Lip

Yes, specifyNo

Cleft Palate

Yes, specifyNo

Neck

Abnormal, specify

Specify

Cardiovascular System

Heart Rate

beats/min

Pulse Volume

GoodWeakNot felt

Capillary Refilling Time

<= 2 secs

Femoral Pulse

Absent

Apex Beat

Not felt

Heart Sounds

Heart Murmur

No

Pulse Oxymetry Screening

hours of life

Preductal Right Hand SPO2 (%)

Postductal Right Leg SPO2 (%)

Postductal Left Leg SPO2 (%)

Respiratory System

Respiratory Rate

breaths/min

Stridor

No

Nasal Flaring

No

Grunting

No

Respiratory Effort

Good

Chest Recession

No

Chest

Normal

Lungs

Breath sounds

Additional sounds

Abdomen

Shape

Distended

Liver

Not Palpable

Spleen

Not Palpable

Kidney

Not ballotable

Bowel Sounds

Absent

Anus

Imperforate

Fistula

No

Umbilicus

Abnormal, specify

Genitalia

Male

Testes

Descended

Urethral opening

Abnormal

Hypospadias

Hydrocele

Other Abnormalities

Female

Enlarged Clitoris

No

Labial Adhesions

No

Impeforate Hymen

No

Vaginal Bleed

No

Other Abnormalities

Indeterminate

Musculoskeletal

Spine

Abnormal, specify

Upper Limbs

Abnormal, specify

Lower Limbs

Abnormal, specify

Hips

Ortolani

Negative

Barlow

Negative

Ctev

Neurological

Posture

Flexed

Activity

Active

Cry

Tone

Hypertonic

Movement

None

Sucking Reflex

None

Moro's Reflex

Absent

Grasp Reflex

Absent

Skin

Normal

Other Abnormality

IMPRESSION

Impression

DIAGNOSIS

Diagnosis

MANAGEMENT

Orders

Referral

Outgoing Referrals

Comments

Plan

SIGNATURES

Notes Component

MATERNAL HISTORY
BABY'S RECORD
PHYSICAL EXAMINATION
IMPRESSION
DIAGNOSIS
MANAGEMENT
SIGNATURES

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