Visit Documentation Forms: First Week Visit (3 to 5 Days)

Visit Documentation Form: First Week Visit (3 to 5 Days)

Name

ID number

Date of Birth

Age

Accompanied By

Preferred Language

Date and Time

Weight (%)

Length (%)

HC (%)

Vital if (Indicated)

Temp

Resp Rate

Spo2

HISTORY

Concerns and Questions

Medical History

Infant has special Areas reviewed and updated as needed

Past Medical History (See Initial History Questionnaire.)

Surgical History (See Initial History Questionnaire.

Problem List (See Problem List.)

Medications

No known drug allergies

Reviewed and updated (See Medication Record.)

Allergies

No known drug allergies

Birth History

Full Term

Pre-Term

Post-Term

Vaginal

Caesarian

Apgar

If Pre-term / Post Term, Weeks?

Apgar (1 min/5 min/10 min)

Birth weight

Discharge weight

Percent weight loss since birth

Newborn hearing screening

Passed BL Referred Not done

If Referred, Specify

Newborn blood screening

Collected Not done

If Collected, specify

CCHD screening

Passed Referred Not done

If Passed, specify

Blood type

Maternal Infant

Coombs test/DAT

Pos Neg N/A

Bilirubin screening

DEVELOPMENT

Normal development

See Pre-visit Questionnaire.

If yes, specify

SOCIAL LANGUAGE AND SELF-HELP

Makes brief eye contact

GROSS MOTOR

Reflexively moves arms and legs
Turns head to side when on stomach

SOCIAL LANGUAGE AND SELF-HELP

Holds fingers closed
Grasps reflexively

SOCIAL AND FAMILY HISTORY

Areas reviewed and updated as needed (See Initial History Questionnaire.)

Social History

Family History

Smoking household

Yes

If yes, Specify

Parent adjustment to new infant

Reactions of sibling to new infant

Work plans

REVIEW OF SYSTEMS

A 10-point review of systems was performed and results were negative except for any positive results listed below.

Required Field = Focus area for this Bright Futures Visit

Constitutional

Respiratory

Skin

Eyes

Gastrointestinal

Neurological

Head, Ears, Nose, and Throat

Genitourinary

Other

Cardiovascular

Musculoskeletal

Other

PHYSICAL EXAMINATION

Required Field = Focus area for this Bright Futures Visit

General: Alert, active infant. No congenital anomalies or dysmorphic features

Head: Normocephalic and atraumatic. Normal sutures. Anterior fontanelle open and flat

Eyes: Normal eyes and eyelids. Fixes and follows. Red reflex present bilaterally. No opacification. Normal funduscopic examination findings.

Ears, nose, and throat: Normal external ears, no pits or tags, nares patent, and palate intact.

Neck: Supple, with full range of motion without torticollis

Heart: Regular rate and rhythm. No murmur. Equal symmetrical femoral and upper extremity pulses

Respiratory: Breath sounds clear bilaterally. Comfortable work of breathing without retractions

Abdomen: Soft, with no palpable masses. Well-appearing dry umbilical stump

Genitourinary:

Normal female external genitalia. No significant labial swelling

Normal male external genitalia, with testes palpable in scrotum bilaterally

Musculoskeletal: Spine straight without dimples, sinus tracts, or hair tufts. Clavicles intact. Negative Ortolani and Barlow maneuvers.

Neurological: Moves all extremities equally. Normal posture and tone. Normal neonatal reflexes

Skin: Warm and well perfused. No rashes or jaundice. No birthmarks or lesions

Other comments

ASSESSMENT

Well child

Normal interval growth (See growth chart.)

Age-appropriate development

ANTICIPATORY GUIDANCE (Discussed and/or handout given )

SOCIAL DETERMINANTS OF HEALTH

Living situation and food security
Environmental tobacco exposure
Family support

NUTRITION AND FEEDING

General feeding guidance
Breast/formula-feeding guidance

SAFETY

Car safety seats
Safe sleep
Heatstroke prevention
Burn prevention

PARENT AND FAMILY HEALTH

Transition home and sibling adjustment

NEWBORN BEHAVIOR AND CARE

Early brain development; calming
When to call; CPR; illness prevention

PLAN

(Immunization) Vaccine Administration Record reviewed

Administered today

Up-to-date for age

Universal Screening

Newborn blood screening

Result

Pending

Normal

Needs Follow Up

Newborn hearing screening

Result

Passed BL

Referred right/left/BL

Needs follow-up

Selective Screening (based on risk assessment) (See Previsit Questionnaire.):

Vision

Comments/results:

Follow-up

Routine follow-up at 1 month

Next visit

Referral to

Next Visit

Referral to

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