Newborn Clinical Forms

Initial Assessment Form & New-Born Case Record Sheet — digitised from the Paramitha Children's Hospital record set. Fields marked * are mandatory.

Draft

Initial Assessment Form

New-Born Case Record Sheet

Patient Identification

Header

Name

Hospital

Registration No.

Obstetrician

Father Name

Antenatal Details

Mother's age at conception (years)

Mother's Blood Group

Parity *

Gravida

Para

Live Born

Abortions

Death

Conception

Details

Consanguinity

Tetanus

LMP

EDD *

Scans *

EDD

Any malformations

Liquor

Dopplers

Any H/O *

PIH

GDM

APH

UTI or any febrile illness

PPROM

If delivered preterm *

Reason for prematurity

Antenatal steroids

Magnesium sulphate

Antibiotics for PPROM

Delayed cord clamping

Mode of delivery

Indication for LSCS

Baby Details

Date of birth

Time of birth

Sex

Gestation

Weight

Length

Growth

Baby's Foot Print

Foot print area
Affix / scan the print here

Resuscitation Details

Amniotic fluid

Cried immediately after birth *

Resuscitation *

Resuscitation measures

APGAR scores

At 1 min

At 5 min

At 10 min

Vitals at Admission

Baseline

Serial Vitals Monitoring

Date & time	Temp (°C)	HR (/min)	RR (/min)	SpO₂ (%)	NIBP (mmHg)	CRT	Recorded by

Record 6th hourly, or more often if the baby is unstable.

General & Systemic Examination

Impression & Plan

Impression

Plan

Advice

Any Special Advice

Special advice

Investigations

Spo2 at room air — Right UL

Spo2 at room air — Right LL

Blood group

Cord TSH

ENBS

Vaccination

OPV

Hepatitis B

BCG

SOAP Note

Drafted from the fields above. Review and edit before signing — the clinician remains responsible for the note.

S — Subjective

O — Objective

A — Assessment

P — Plan

Demographic Details

Name of the baby *

Admission No.

Fathers Name

Sex *

Address

Date of birth *

Time of birth *

Age *

Date of admission *

Antenatal Details

Mother's age at conception (years)

Booked at *

Parity *

Gravida

Para

Live Born

Abortions

Death

Conception

Consanguinity

LMP

EDD *

Tetanus

Scans *

EDD

Any malformations

Liquor

Dopplers

Any H/O *

PIH

GDM

APH

UTI or any febrile illness

PPROM

If delivered preterm *

Reason for prematurity

Antenatal steroids

Magnesium sulphate

Antibiotics for PPROM

Intrapartum Details

Mode of delivery *

If LSCS (reason for LSCS)

Amniotic fluid

Cried immediately after birth *

Resuscitation *

Resuscitation measures

APGAR scores

At 1 min

At 5 min

At 10 min

Gestation at birth * (weeks)

Presenting Complaints

Tick all that apply

Any other complaints — details

Birth Anthropometry

Weight (grams) *

Weight — 2nd reading

Centiles on Fenton

Length (cm) *

Length — 2nd reading

Centiles on Fenton

Head circumference (cm) *

HC — 2nd reading

Centiles on Fenton

Gestational Age Assessment

New Ballard Score

Physical score

Neurological score

Total score

Gestational age

Vitals

General Examination

Pallor / Icterus / Cyanosis / Edema

Serial Vitals Monitoring

Date & time	Temp (°C)	HR (/min)	RR (/min)	SpO₂ (%)	NIBP (mmHg)	CRT	Recorded by

Record 6th hourly, or more often if the baby is unstable.

Systemic Examination

Respiratory System

Per Abdomen

Cardiovascular System

Central Nervous System

SOAP Note

Drafted from the fields above. Review and edit before signing — the clinician remains responsible for the note.

S — Subjective

O — Objective

A — Assessment

P — Plan