Sample Type / Medical Specialty: Office Notes
Sample Name: Normal Newborn H&P Template
Template for History and Physical for a newborn.
(Medical Transcription Sample Report)
HISTORY OF PRESENT ILLNESS:
This is a ** week gestational age ** delivered by ** at ** on **. Gestational age was determined by last menstrual period and consistent with ** trimester ultrasound. ** rupture of membranes occurred ** prior to delivery and amniotic fluid was clear. The baby was vertex presentation. The baby was dried, stimulated, and bulb suctioned. Apgar scores of ** at one minute and ** at five minutes.PAST MEDICAL HISTORYMATERNAL HISTORY:
The mother is a **-year-old, G**, P** female with blood type **. She is rubella immune, hepatitis surface antigen negative, RPR nonreactive, HIV negative. Mother was group B strep **. Mother's past medical history is **.PRENATAL CARE:
Mother began prenatal care in the ** trimester and had at least ** documented prenatal visits. She did not smoke, drink alcohol, or use illicit drugs during pregnancy.SURGICAL HISTORY:
Medications taken during this pregnancy were **.ALLERGIES:
VITAL SIGNS: Temperature **, heart rate **, respiratory rate **. Dextrose stick **. Ballard score by the RN is ** weeks. Birth weight is ** grams, which is the ** percentile for gestational age. Length is ** centimeters which is ** percentile for gestational age. Head circumference is ** centimeters which is ** percentile for gestational age.
GENERAL: **Alert, active, nondysmorphic-appearing infant in no acute distress.
HEENT: Anterior fontanelle open and flat. Positive bilateral red reflexes.
Ears have normal shape and position with no pits or tags. Nares patent. Palate intact. Mucous membranes moist.
NECK: Full range of motion.
CARDIOVASCULAR: Normal precordium, regular rate and rhythm. No murmurs. Normal femoral pulses.
RESPIRATORY; Clear to auscultation bilaterally. No retractions.
ABDOMEN: Soft, nondistended. Normal bowel sounds. No hepatosplenomegaly. Umbilical stump is clean, dry, and intact.
GENITOURINARY: Normal tanner I **. Anus patent.
MUSCULOSKELETAL: Negative Barlow and Ortolani. Clavicles intact. Spine straight. No sacral dimple or hair tuft. Leg lengths grossly symmetric. Five fingers on each hand and five toes on each foot.
SKIN: Warm and pink with brisk capillary refill. No jaundice.
NEUROLOGICAL: Normal tone. Normal root, suck, grasp, and Moro reflexes. Moves all extremities equally.DIAGNOSTIC STUDIESLABORATORY DATA:
Full term, appropriate for gestational age **.PLAN:
1. Routine newborn care.
2. Anticipatory guidance.
3. Hepatitis B immunization prior to discharge.
office notes, history and physical, gestational age, newborn, prenatal,
transcribed medical transcription sample reports and examples are provided by various users and
are for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.
These transcribed medical transcription sample reports may include some uncommon or unusual formats;
this would be due to the preference of the dictating physician. All names and dates have been
changed (or removed) to keep confidentiality. Any resemblance of any type of name or date or
place or anything else to real world is purely incidental.