NEWBORN 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]