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Pediatrician
25-30 minutes

Neonate (AWJ) Template

The s10.ai newborn documentation template is expertly crafted for pediatricians to streamline the recording of vital newborn health and developmental information. This comprehensive template includes sections on birth and nursery details, feeding and weight tracking, household safety, and developmental milestones, ensuring thorough newborn assessments. By utilizing this template, pediatricians can enhance communication with parents and caregivers, capturing crucial data during the critical early days post-birth. This tool is essential for documenting all necessary health evaluations and safety protocols, making it an invaluable resource for pediatric healthcare providers.

4,226 uses
4.8/5.0
D
Dr. Emily Carter
Template Structure

Organized sections for comprehensive clinical documentation

[s10.ai] is a [how many day old] newborn.
Birth/Nursery:
Baby was born at [KMCWC(Kapiolani), Queens Medical Center, Castle Medical Center] and was discharged home on [date discharged home].
[week GA] by [NSVD or C-section].
Mom [G,P]. Maternal labs [unremarkable, significant for]. Maternal hx and pregnancy [unremarkable, significant for].
Baby [passed, did not pass] CCHD. [Passed, did not pass] hearing screen.
Baby received Hep B immunization, Vit K and erythromycin.
[discussion of bilirubin, phototherapy]
Feeding/weight:
Birth weight was [birth weight]. [Weight today is what % down from BW].
Has been [breast feeding, formula feeding] for minutes every hours.
[If breastfeeding, include if baby is latching well and if mom's breastmilk is in now, if mom is comfortable with how feeds are going. ]
[In the last 24 hours, has baby had adequate wet diapers and stools]
Household/Safety:
Lives with: [who lives in the household]
[Baby is sleeping in own crib on back]
[Baby has a rear facing car seat in the back seat of the car]
Baby is doing the following:
- Stays awake for a short time to feed.
- Makes brief eye contact
- Cries when uncomfortable.
- Calms to an adult’s voice.
- Lifts and turns head to the side briefly when on tummy.
- Moves arms and legs at the same time when startled.
- Keeps hands in a fist and grasps reflexively
Sample Clinical Note

Example of completed documentation using this template

Baby John Doe is a 3-day-old newborn.
Birth/Nursery:
Baby was born at Kapiolani and was discharged home on October 15, 2023. 39 weeks GA by NSVD. Mom G2, P1. Maternal labs unremarkable. Maternal hx and pregnancy unremarkable. Baby passed CCHD. Passed hearing screen. Baby received Hep B immunization, Vit K and erythromycin. Bilirubin levels were within normal range, no phototherapy required.
Feeding/weight:
Birth weight was 3.2 kg. Weight today is 5% down from BW. Has been breastfeeding for 20 minutes every 2 hours. Baby is latching well, and mom's breastmilk is in now. Mom is comfortable with how feeds are going. In the last 24 hours, baby had adequate wet diapers and stools.
Household/Safety:
Lives with: mother, father, and older sibling. Baby is sleeping in own crib on back. Baby has a rear-facing car seat in the back seat of the car.
Baby is doing the following:
- Stays awake for a short time to feed.
- Makes brief eye contact
- Cries when uncomfortable.
- Calms to an adult’s voice.
- Lifts and turns head to the side briefly when on tummy.
- Moves arms and legs at the same time when startled.
- Keeps hands in a fist and grasps reflexively.
Clinical Benefits

Key advantages of using this template in clinical practice

  • This comprehensive newborn clinical template is designed to streamline the documentation process for healthcare professionals, ensuring accurate and efficient recording of essential newborn information. It covers critical aspects such as birth and nursery details, feeding and weight monitoring, and household safety, providing a holistic view of the newborn's health status. The template includes sections for documenting birth weight, feeding patterns, and developmental milestones, as well as safety measures like car seat usage and sleep arrangements. By utilizing this template, clinicians can ensure thorough and consistent patient records, facilitating better communication with caregivers and enhancing newborn care. Explore and implement this template to optimize your clinical workflow and improve patient outcomes.
Frequently Asked Questions

Common questions about this template and its usage

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