Well Child Exam - Infancy: Newborn-1 Week Visit - Ohio Department Of Job And Family Services

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WELL CHILD EXAM-INFANCY: Newborn–1 Week Visit
DATE
PATIENT NAME
DOB
SEX
PARENT NAME
Allergies
Current Medications
Prenatal/Family History
Chief Complaints
Weight
Percentile
Length
Percentile
HC
Percentile
Temp.
Pulse
Resp.
BP (if risk)
%
%
%
□ Vaginal □ C-Section
Birth History
Anticipatory Guidance/Health Education
(√ if discussed)
Complications □ Y □ N
Birth Wt.: _________ Gestation: ____________
Safety
Interval History:
□ Y
□ N
Patient Unclothed
□ Appropriate car seat placed in back seat
(Include injury/illness, visits to other health
□ Keep home and car smoke-free
Review of
Physical
care providers, changes in family or home)
□ Keep hot liquids away from baby
Systems
Exam
Systems
□ To protect baby, avoid crowded places
N
A
N
A
□ Don’t leave baby alone in tub or high
General
□
□
□
□
places; always keep hand on baby
Appearance
□ Water temp. <120 degrees/test with wrist
Skin/nodes
Apnea □ Y □ N □ Monitor
□
□
□
□
□ Never shake baby
Jaundice
Nutrition
Nutrition
□
□
□
□
□ Breast every ______ hours
Head
□ Hold baby when feeding/don’t prop bottle
□ Formula ____ oz every _____ hours
□ Breast on demand or feed iron-fortified
□
□
□
□
With iron □ Y □ N
Eyes
formula
Type or brand
□ Breast milk or formula is only fluid/food
□
□
□
□
Ears
_____________________________
infant needs
□ City water
□ Well water
□
□
□
□
□ Amount of diaper changes to expect
Nose
Elimination
Infant Care
□ Normal
□ Abnormal
□
□
□
□
Oropharynx
□ Thermometer use; antipyretics
Sleep
□ Wash hands often
□ Normal (2-4 hours)
□ Abnormal
□
□
□
□
Gums/palate
□ Avoid direct sun/use children’s sunscreen
Additional area for comments on page 2
□ Emergency procedures
□
□
□
□
WIC
Neck
Infant Development
□ Y □ N
□ Develop feeding/sleep routines
□
□
□
□
Maternal Infant Health Managed Care
Lungs
□ Put baby to sleep on back/Safe Sleep
□ Y □ N
Program (MCP)
□ Put baby to sleep in own crib
□
□
□
□
Heart/pulses
Name:_________________
□ Console, hold, cuddle, rock, play w/baby
□
□
□
□
Family Adjustment
Abdomen
Screening and Procedures:
□ Take time for self and partner
Neonatal Metabolic Screen in Chart
□
□
□
□
□ Substance Abuse, Child Abuse, Domestic
Genitalia
□ Y □ N Test Date: _______
Violence Prevention
□ Normal □ Pending
□ Today
□
□
□
□
Spine
□ Rest/sleep when baby sleeps
Hearing
Parental Well Being
□ Responds to Sounds
□
□
□
□
Extremities/hips
□ Postpartum Check-up, Family Planning
□ Neonatal ABR or OAE results in chart
□ Baby blues, postpartum depression
Developmental Surveillance
□
□
□
□
Neurological
□ Accept help from partner, family & friends
□ Social-Emotional □ Communicative
□ Abnormal Findings and Comments
□ Cognitive □ Physical Development
Other Anticipatory Guidance Discussed:
Psychosocial/Behavioral Assessment
□ Y □ N
( see additional note area on next page)
□ Y □ N
Screening for Abuse
Results of visit discussed with parent □ Y □ N
If At Risk
□ Vision -Parental observation/concerns
Plan
Immunizations:
□ History/Problem List/Meds Updated
HepB Given in Hospital?
Next Well Check: 1 month of age
□ Referrals
□ Maternal Infant Health MCP
□ Y
□ N
□ Today
Developmental Questions and Observations
□ Immunizations Reviewed
□ WIC □ Help Me Grow
□ Transportation
TM
on Page 2
□ Immunizations Given & Charted – if not
□ Children Special Health Care Needs
Provider Signature:
given, document rationale
□ Other referral_________________
□ IMPACTSIIS checked/updated
□ Other ________________________________
Labs Done Today
□ Y □ N
This screening form was adapted by the Ohio Medicaid managed care plans and Ohio Department of Job and Family Services for the
Healthchek-EPSDT Collaborative Performance Improvement Project.
040110

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