Newborn Admission Note (Hospital)

Facility/Unit: [Facility or unit name]    Date/Time of Note: [Date and time of documentation]    Author/Role: [Name and role]    Attending of Record: [Attending physician name]

Newborn Name: [Infant name or "Baby of"]    MRN: [Medical record number]    DOB: [Date and time of birth]    Sex: [male / female / indeterminate / unknown]

Gestational Age at Birth: [Gestational age in weeks+days]    Age at Exam (hours): [Hours of life at time of exam]    Day of Life: [DOL number]

[One-line opening summary: gestational age, sex, delivery mode, maternal G/P, current clinical status] (Compose a single concise sentence; do not invent data.)

Birth and Delivery Summary

Delivery: [Date/time of delivery], [Location]

Delivery Type: [spontaneous vaginal / assisted vaginal (forceps/vacuum) / cesarean (scheduled/urgent/emergent)] (If operative, include indication.)

Presentation: [cephalic / breech / transverse / unknown]

Apgar Scores: [1 min score] at 1 min; [5 min score] at 5 min [; 10 min score if documented]

Anthropometrics at Birth: Weight [value + units]; Length [value + units]; Head circumference [value + units]; [AGA / SGA / LGA] (Include percentiles if available.)

Membrane Rupture: [Duration from ROM to delivery], [clear / meconium-stained / bloody / unknown]

Maternal Intrapartum Fever: [Highest temperature or "none"]

Resuscitation: [none / routine steps only / oxygen / PPV / CPAP / intubation / chest compressions / medications] (Summarize infant response if described.)

Delayed Cord Clamping: [yes / no / unknown] [duration if known]

Intrapartum Antibiotics: [Agent(s)], [GBS prophylaxis / suspected intra-amniotic infection / other], started [time], [duration] before delivery (If not administered, state explicitly.)

Newborn Prophylaxis: Vitamin K [dose, route, time / declined with counseling documented]; Eye prophylaxis [agent, time / declined with counseling documented]; Hepatitis B vaccine [given with time / deferred with reason and shared decision-making outcome]

Maternal and Prenatal History

Obstetric History: [Gravida/Para], [relevant prior outcomes], [prenatal care: early / late / limited / none]

Maternal Conditions Affecting Newborn: [Diabetes (pregestational/gestational) / hypertension or preeclampsia / thyroid disease / HSV status and suppressive therapy / substance exposures / relevant medications / none reported] (List only those explicitly documented.)

Prenatal Labs: (If unavailable, state "unavailable" with plan to obtain. Do not infer negatives.)

• Blood type/Rh/antibody screen: [result, date / unavailable]
• HBsAg: [result, date / unknown - plan to obtain urgently] (If positive or unknown, document prophylaxis plan below.)
• HIV: [result, date / unknown - expedited testing planned] (If positive or unknown, document ARV plan.)
• Syphilis: [result, date; treatment adequacy if positive / unknown]
• Rubella immunity: [immune / non-immune / unknown], [date]
• GBS culture: [positive / negative / unknown], [collection date]
• GC/CT: [results, dates / not available]
• Hepatitis C: [result, date / not known]

Pregnancy Complications: [IUGR / oligohydramnios / polyhydramnios / suspected chorioamnionitis / prenatal ultrasound anomalies / none reported]

Targeted Family History: [Hemolytic disease / G6PD deficiency risk / sibling jaundice requiring phototherapy / congenital heart disease / early hearing loss / metabolic disease on sibling newborn screen / none / unknown]

Newborn Course Since Birth

• Vitals/Thermoregulation: [stable / unstable]; [open crib / radiant warmer / skin-to-skin]
• Feeding: [breast / formula / combination]; [latch quality]; [volumes and frequency if bottle-fed]
• Output: Urine [count]; Stool [count] since birth
• Symptoms/Events: [emesis / respiratory distress / color changes / abnormal movements / none]
• Glucose Monitoring: [indication], [values with times], [interventions] (Include only if screening performed.)

Physical Examination

Vital Signs: Temp [value, source], HR [value], RR [value], SpO2 [value, room air vs supplemental] (if measured)

Anthropometrics: Birth weight [value]; Current weight [value] ([percent change]); Length [value]; Head circumference [value]

• General: [well-appearing / mild distress / distress]; [tone and activity level]
• Skin: [color/perfusion]; [jaundice extent by zones if present]; [bruising / cephalohematoma / birthmarks]
• Head/Neck: [fontanelles]; [molding/caput]; [palate intact / cleft]
• Eyes: [red reflex present bilaterally / absent / not assessed with reason and plan]
• Cardiovascular: [rate/rhythm]; [murmur present / absent]; [femoral pulses]; [capillary refill]
• Respiratory: [work of breathing]; [breath sounds]; [retractions / grunting / nasal flaring]
• Abdomen: [soft / distended]; [organomegaly]; [umbilical stump]
• Genitourinary: [normal female / normal male]; [testes descended if male]; [meatus position]
• Anus: [patency confirmed / not confirmed with plan]
• Musculoskeletal: [clavicles intact]; [spine/sacrum]; [hips stable / clicks / instability]
• Neurologic: [tone]; [primitive reflexes]; [suck]

Studies

(Include only studies actually performed.)

• Bilirubin: [value], [TcB / TSB], [date/time], infant age [hours] at measurement
• Infant Blood Type/DAT: [results, date]
• Glucose: [values with times]
• Cord Gases: [arterial/venous values] (If clinically relevant.)

Newborn Screening Status:

• Metabolic blood spot: [collected date/time / pending / resulted: normal / abnormal with details]
• Hearing screen: [pass / refer (specify ear) / pending], [date/time]
• CCHD screen: [pass / fail / pending], [date/time]

Assessment

[Summary of clinical picture, perinatal context, and notable risk factors]

• [Problem 1]: [Assessment including severity and pertinent findings]
• [Problem 2]: [Assessment] (Add additional problems as applicable.)

Plan

(Include only applicable subsections.)

Routine Care and Monitoring

• Vitals: [frequency]
• Thermal care: [open crib / skin-to-skin / radiant warmer]
• Daily weights: [yes / no]
• Prophylaxis status: Vitamin K [given / declined]; Eye prophylaxis [given / declined]; Hepatitis B vaccine [given / deferred with reason]

Feeding

• Method: [exclusive breastfeeding / exclusive formula / combination]
• Frequency: [on demand every 2-3 hours / cue-based / volume goals]
• Latch/transfer assessment: [description]; Lactation support: [consult placed / bedside coaching / not indicated]
• Supplementation: [not indicated / indicated for (reason) with type/volume/frequency]

Hyperbilirubinemia

• Risk factors: [jaundice <24h / hemolysis or DAT+ / bruising or cephalohematoma / prematurity / sibling phototherapy / G6PD risk / feeding difficulty / excessive weight loss / none]
• Screening plan: [TcB / TSB] at [target hours of life]
• If obtained: [distance from phototherapy threshold]; Follow-up interval: [hours/days]; Criteria for repeat or phototherapy: [specify]

Early-Onset Sepsis Risk

(Include when maternal infection risk factors present.)

• GBS status: [positive / negative / unknown]; Prophylaxis: [adequate (PCN/AMP/CFZ ≥4h before delivery) / inadequate / none]
• Other risk factors: [maternal fever / chorioamnionitis / ROM duration / gestational age]
• Evaluation approach: [serial clinical exams / categorical risk / EOS calculator with result]
• Monitoring plan: Observation [duration], vitals [frequency], indications for labs or empiric antibiotics: [specify]

Hypoglycemia Monitoring

(Include only for at-risk infants.)

• Indication: [IDM / LGA / SGA / late preterm / symptomatic]
• Screening schedule: [timing relative to feeds]; Duration: [hours]
• Intervention thresholds: [values prompting feeding / dextrose gel / IV dextrose]

Newborn Screens

• Metabolic screen: [timing/status]; If abnormal: [follow-up plan]
• Hearing screen: [pass / refer]; If refer: [audiology referral plan]
• CCHD screen: [pass / fail]; If fail: [confirmatory testing plan]

Family Education

• Topics reviewed: [safe sleep / feeding expectations / jaundice signs / when to seek care / cord care]
• Teach-back completed: [yes / no]

Disposition and Follow-up

• Anticipated discharge: [timing/criteria]
• Pediatrician/medical home: [identified / pending]; Follow-up appointment: [timeframe based on risk factors]
• Pending results at discharge: [list with follow-up plan]