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Newborn Exam Template
A newborn exam note records a baby’s first checks: birth history, feeding, weight change, a head-to-toe exam, jaundice, and screens. Copy the free template, see a day-1 and a day-3 example, and check what each part needs.
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- Word and text downloads
- Two filled examples
Blank newborn exam template
FreeNEWBORN EXAM Patient: [Name, or Baby and parent's surname] Date and time of birth: [Date, time] Date and time of exam: [Date, time; age in hours] Setting: [Postpartum unit, nursery, clinic, or home] Parents present: [Who was present for the exam] Examiner: [Name, credentials] BIRTH HISTORY Gestational age: [Weeks and days; how it was dated] Delivery: [Vaginal or cesarean and reason; instruments; presentation] Apgar scores: [1 and 5 minutes; 10 minutes if done] Resuscitation: [None beyond routine care, or what was needed] Birth measurements: [Weight, length, and head circumference with percentiles; appropriate, small, or large for gestational age] Maternal history: [Age, gravida and para, pregnancy complications, medications, substance use] Maternal labs: [Blood type and antibody screen; prenatal infection screens; group B strep status] Infection risk: [Duration of ruptured membranes, maternal fever, intrapartum antibiotics and timing] FEEDING AND WEIGHT Feeding: [Breast, formula, or both; feeds in 24 hours; latch and swallowing; supplement volumes] Voids: [Number in the last 24 hours] Stools: [Number and color in the last 24 hours] Today's weight: [Grams and lb oz] Change from birth weight: [Grams and percent, with age in hours] EXAMINATION Vital signs: [Temperature with route, HR, RR] General: [Color, activity, cry, tone, posture] Head: [Fontanelles, sutures, molding, caput or cephalohematoma] Eyes: [Red reflex in each eye, discharge] Ears, nose, and mouth: [Ear position, pits or tags, nares patent, palate intact by sight and touch, suck] Neck and clavicles: [Masses; clavicles intact] Chest and lungs: [Work of breathing, breath sounds] Heart: [Rate and rhythm, murmur, femoral pulses] Abdomen: [Masses, liver and spleen, umbilical cord with vessel count] Genitalia and anus: [Appearance, testes descended, urethral opening, anus patent and in position] Hips: [Barlow and Ortolani on each side, skin folds, leg length] Spine: [Straight; sacral dimple, hair tuft, or skin changes] Limbs: [Digits, movement of all limbs, arm movement after a difficult delivery] Skin: [Birthmarks, rashes, bruising] Neurological: [Tone, Moro, grasp, root, suck] JAUNDICE Visible jaundice: [None, or how far it extends] Bilirubin: [Transcutaneous or serum value, age in hours at the sample, and where it falls against the threshold in your guideline] Risk factors: [Gestational age, jaundice in the first 24 hours, blood group incompatibility, bruising, a sibling treated, feeding not yet established] SCREENING Blood spot screen: [Collected with time, or when it is due] Hearing: [Pass or refer in each ear] Pulse oximetry: [Right hand and foot values; pass or repeat] Other: [Glucose checks if at risk; blood type and antibody test if indicated] ASSESSMENT Summary: [Gestational age, size for dates, age in hours or days, and overall condition] Problems: [Each finding or problem, and its plan] PLAN Feeding plan: [Frequency, latch support, supplementation if needed, lactation referral] Birth medications: [Vitamin K, eye prophylaxis, and hepatitis B vaccine per local practice; given or declined] Follow-up: [Who sees the baby, and when; weight and bilirubin rechecks] Caregiver education: [Feeding cues, diaper counts, jaundice, safe sleep, car seat, fever and when to seek care] Signed: [Clinician name, credentials, date and time]
Use it for
- Newborn nursery
- Postpartum unit
- First clinic visit
- Home birth follow-up
- Midwifery and family practice
Two filled examples. Every part, filled in.
Each one follows the template. Use them to judge how much detail every part needs.
Newborn exam: healthy term baby, day 1
Postpartum unit, first newborn exam at 18 hours
Birth history
Girl born at 39 weeks 4 days, dated by first-trimester ultrasound. Spontaneous vaginal delivery, head first, no instruments. Apgars 8 and 9. Routine drying and stimulation only. Birth weight 3,520 g (7 lb 12 oz), length 51 cm (20.1 in), head circumference 34.5 cm (13.6 in): appropriate for gestational age. Mother 31 years old, second baby, uncomplicated pregnancy, prenatal vitamins only. Maternal labs: blood type B positive, antibody screen negative; prenatal infection screens negative; rubella immune; group B strep negative. Membranes ruptured 6 hours before birth, clear fluid; no maternal fever; no antibiotics needed.
Feeding and weight
Breastfed 7 times since birth, latching well with audible swallowing. 2 voids and 2 meconium stools so far. Weight 3,440 g (7 lb 9 oz) at 18 hours, down 80 g, 2.3% from birth weight.
Examination
T 36.9 °C (98.4 °F) axillary, HR 136, RR 44. Pink, active, strong cry, flexed posture. Anterior fontanelle soft and flat; mild molding. Red reflex present in both eyes. Ears normally placed, no pits or tags; palate intact by sight and touch; strong suck. Clavicles intact. Breathing comfortably, chest clear. Heart regular, no murmur; femoral pulses strong and equal. Abdomen soft, no masses; three-vessel cord. Normal female genitalia; anus patent. Barlow and Ortolani negative on both sides. Spine straight, no sacral dimple. Moves all limbs. Salmon patch on the nape of the neck; a few erythema toxicum papules on the trunk. Normal tone, Moro, and grasp.
Jaundice
No visible jaundice. Pre-discharge bilirubin to be measured with the blood spot screen after 24 hours. No risk factors: term, mother B positive with a negative antibody screen, no bruising, feeding well.
Screening
Blood spot and pulse oximetry screens due after 24 hours of age. Hearing screen: pass in both ears.
Assessment
Healthy term girl, appropriate for gestational age, 18 hours old. Normal exam. Breastfeeding well; weight loss as expected for her age.
Plan
Breastfeed on demand, at least 8 to 12 times in 24 hours. Vitamin K 1 mg IM given at birth; eye prophylaxis and hepatitis B vaccine per local practice, recorded on the birth record. Bilirubin, blood spot, and pulse oximetry screens after 24 hours. Vitamin D 400 IU daily while breastfed. Clinic visit within 48 hours of discharge for weight, feeding, and jaundice. Parents taught: on her back to sleep in her own crib in their room, rear-facing car seat, feeding cues, and diaper counts. Seek care right away for a temperature of 38.0 °C (100.4 °F) or higher, poor feeding, or yellow color spreading to the belly or legs.
Newborn exam: day 3 with mild jaundice
Primary care clinic, first visit after discharge, 68 hours old
Birth history
Boy born at 39 weeks 2 days by spontaneous vaginal delivery after an uncomplicated pregnancy. Apgars 9 and 9. Birth weight 3,400 g (7 lb 8 oz), appropriate for gestational age. Mother 28 years old, first baby. Maternal labs: blood type A positive, antibody screen negative; prenatal infection screens negative; group B strep negative. Discharged at 36 hours. Pre-discharge transcutaneous bilirubin at 30 hours: 6.8 mg/dL (116 µmol/L), well below the phototherapy threshold.
Feeding and weight
Exclusively breastfed 8 to 9 times in 24 hours, 20 to 40 minutes a feed. His mother has sore nipples and says her milk is starting to come in today. 4 wet diapers and 3 stools in the last 24 hours, stools changing from dark green to brown. Weight 3,130 g (6 lb 14 oz) at 68 hours, down 270 g, 7.9% from birth weight.
Examination
T 37.0 °C (98.6 °F) axillary, HR 140, RR 42. Alert and vigorous, good tone. Yellow skin to the chest; sclerae yellow. Anterior fontanelle soft and flat. Moist mucous membranes. Red reflex present in both eyes. Heart regular, no murmur; femoral pulses normal. Abdomen soft; cord drying. No bruising or cephalohematoma. Hips stable. Observed feed: shallow latch, better with positioning help, then rhythmic sucking with audible swallows.
Jaundice
Visible to the chest. Transcutaneous bilirubin 12.4 mg/dL (212 µmol/L) at 68 hours, plotted on the hour-specific chart in the local guideline: well below the phototherapy threshold for his gestational age and risk factors. Risk factor: exclusive breastfeeding while milk supply builds. Term, no blood group incompatibility, no bruising, no sibling treated for jaundice.
Screening
Blood spot screen collected at 26 hours; result pending, to come to the clinic. Hearing: pass in both ears. Pulse oximetry: right hand 98%, foot 98%; passed.
Assessment
Healthy term boy, 3 days old. Physiological jaundice, well below the treatment threshold. Weight down 7.9% with breastfeeding still being established; output is adequate for day 3, and milk is coming in.
Plan
Feed at least 8 to 12 times in 24 hours, waking him if 3 hours pass. Latch and positioning reviewed; lactation consultant visit booked for tomorrow; nipple care discussed. No supplement needed today; if he is too sleepy to feed, give hand-expressed milk by spoon and call the clinic. Recheck weight, feeding, and jaundice in 2 days. Seek care the same day for fewer than 4 wet diapers a day, yellow color spreading to the legs, a baby too sleepy to wake for feeds, pale stools, or a temperature of 38.0 °C (100.4 °F) or higher.
What goes in each part.
Birth history
The risks the baby carries from pregnancy and delivery. Later decisions about jaundice, infection, and glucose depend on them.
- Gestational age, and how it was dated
- Delivery, Apgar scores, and any resuscitation
- Maternal blood type, antibody screen, and prenatal infection screens
- Infection risk: ruptured membranes, maternal fever, group B strep status, and antibiotics
Avoid: “Uncomplicated pregnancy” with no maternal labs. Blood type, antibody screen, and group B strep status change the baby’s plan.
Feeding and weight
Feeds, voids, stools, and weight change show whether intake is enough.
- Feeds in 24 hours, latch, and any supplement volumes
- Voids and stools for the baby’s age, with stool color
- Today’s weight, and the change from birth weight in grams and percent
- The baby’s age in hours at the weight
Avoid: Writing only “feeding well”. Output and weight change show whether it is true.
Examination
A head-to-toe exam that includes the newborn checks that are easy to miss.
- Fontanelles, sutures, and the palate by sight and touch
- Red reflex in each eye
- Heart sounds and femoral pulses
- Hips by Barlow and Ortolani on each side
- Spine and sacrum, genitalia, and anus
Avoid: “Normal newborn exam” as a single line. Name the checks that are easy to miss: red reflex, palate, hips, and femoral pulses.
Jaundice
Whether jaundice is visible, the bilirubin value, and where it falls for the baby’s age in hours.
- Age in hours when the bilirubin was measured
- Transcutaneous or serum value, in the units your lab reports
- Where it falls against your guideline’s threshold, and the risk factors used
- When to recheck
Avoid: Estimating bilirubin from skin color. Visual estimates are unreliable, especially in darker skin; measure it.
Screening
Which newborn screens are done, pending, or due, so nothing is missed at discharge.
- Blood spot screen, with the time collected
- Hearing screen result for each ear
- Pulse oximetry screen for critical congenital heart disease
- Glucose checks if the baby is at risk
Avoid: Leaving a pending screen without saying who will follow up the result.
Plan
Feeding, birth medications, follow-up, and what the parents were taught.
- Feeding frequency and any support or supplementation
- Vitamin K and the other birth medications per local practice
- Who sees the baby next, and when
- The warning signs taught to the parents
Avoid: Generic education. Write the specific signs you taught, such as a temperature of 38.0 °C (100.4 °F) or higher.
Common mistakes, and how to avoid them.
Weight loss without a percentage
Write the grams lost and the percent of birth weight, with the baby’s age in hours. A 7% loss at 24 hours and at 72 hours mean different things.
Plotting bilirubin by day, not by hour
Treatment thresholds change by the hour in the first days. Record the baby’s exact age in hours when the sample was taken.
Examining a crying or dressed baby
Hips, heart sounds, and femoral pulses are easiest to check in a settled, undressed baby. Note any part of the exam that was limited, and repeat it before discharge.
Discharge without a follow-up time
A baby discharged early needs a check of weight, feeding, and jaundice within 1 to 2 days. Write the time and place, not just “follow up with the clinic”.
Missing late maternal results
Results that arrive after birth, such as a group B strep or infection screen, can change the baby’s plan. Check for them before discharge and record that you did.
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Frequently asked questions.
What should a newborn exam note include?
Birth history with gestational age, Apgar scores, and maternal labs; feeding, voids, and stools; weight change from birth; a head-to-toe exam including red reflex, palate, hips, and femoral pulses; jaundice with the bilirubin by age in hours; newborn screens; and the follow-up plan.
Is a newborn exam the same as a newborn H&P?
Mostly. The newborn H&P is the first full exam with the maternal and birth history, usually in the first 24 hours. Later exams, before discharge or at the first clinic visit, are shorter and focus on feeding, weight, jaundice, and screens.
How much weight loss is normal in a newborn?
Most newborns lose weight in the first 3 to 4 days and are back to birth weight by 10 to 14 days. A loss above 7% calls for a careful feeding assessment, and 10% or more needs a feeding plan and close follow-up.
Should bilirubin be in mg/dL or µmol/L?
Use the units your lab reports, and plot the value on the chart your guideline uses. To convert, 1 mg/dL is about 17.1 µmol/L.
How do you document the newborn hip exam?
Record Barlow and Ortolani on each side with the result, plus skin folds and leg length. Note risk factors such as breech presentation, which may need hip imaging per local guidance even when the exam is normal.
Is this newborn exam template free?
Yes. Copy it, or download it as a Word or text file. No account needed.
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