Zachary LaFontaine Objective Data Collection: 24.33 of 25 (97.32%)
- Correct
- Partially correct
- Incorrect
- Missed
- Below 5th percentile
- Between 5th and 95th percentile
- Above 95th percentile
- Growth curve maintained
- Growth curve decline
- Below 5th percentile
- Between 5th and 95th percentile
- Above 95th percentile
Samantha Monroe shadow health Treatment plan
- Growth curve maintained
- Growth curve decline
- Below 5th percentile
- Between 5th and 95th percentile
- Above 95th percentile
- Growth curve maintained
- Growth curve decline
- Below 5th percentile
- Between 5th and 95th percentile
- Above 95th percentile
- Growth curve maintained
- Growth curve decline
- Pale
- Pink
- Erythematous
- Thin white mucus present
- Thick yellow mucus present
- Patent
- Obstructed, not patent single sided
- Ears set appropriately
- Ears low set, posteriorly rotated
- Pinna flexible
- Pinna stiff
- Frenulum intact
- Frenulum thick
- Palate intact
- Palate open
- Tongue smooth
- Tongue rough
- Uvula midline
- Uvula absent
- Cyanosis
- Jaundice
- Pallor
- Congruent with genetic background
- Smooth
- Rough
- Warm
- Cool
- Elastic
- Tenting
- Sluggish turgor
- No visible lesions
- Laceration/wounds
- Erythema
- Ecchymosis
- Birthmark
- Discolorations
- Moist
- Dry
- Intact
- Cracked
- Blistered
- Pink
- Pale
- Erythematous
- No lesions present
- Macerated
- Edema
- Erythema
- Urethral meatus midline
- Hypospadias
- Ambiguous genitalia
- Testes present bilaterally
- Testes not palpable
- Smooth
- Rough
- No masses
- Mass palpable
- Swelling
- Circumcised
- Uncircumcised
- Positive
- Negative
- Positive
- Negative
- Round
- Abnormal shape
- No reaction to light
- Reacts to light symmetrically
- Reacts to light asymmetrically
- Clear
- Cloudy
- Absent
- Present
- Equal color bilaterally
- Unequal color bilaterally
- Opacity absent
- Opacity present
- Follows object in both directions
- Does not follow object in both directions
- Moves all extremities
- Does not move all extremities
- Movement symmetrical
- Movement asymmetrical
- Intact
- Not Evident
- Strong
- Weak
- Symmetrical
- Asymmetrical
- Absent
- Normal Response
- Weak response
- Absent response
- Hearing intact
- Hearing absent
- Symmetrical
- Asymmetrical
- Absent
- Present
- Absent
- Regular
- Irregular
- Equal bilaterally
- 0
- +1
- +2
- +3
- Normal response
- Weak response
- Absent response
- Normal response
- Weak response
- Absent response
- Normal response
- Absent response
- Present
- Absent
- Soft
- Firm
- Distended
- Mass
- Bulges
- Nontender
- Tender
- Sunken
- Flat
- Bulging
- Sunken
- Flat
- Bulging
- Protuberant
- Flat
- Scaphoid
- Absent
- Hypoactive
- Normoactive
- Hyperactive
- Regular Rate
- Irregular Rate
- Regular rhythm
- Arrhythmia
- S1
- S2
- S3
- S4
- Murmurs
- Symmetrical chest rise
- Asymmetrical chest rise
- Clear to auscultation
- Wheezing
- Stridor
- Grunting
- Absent
- Smooth, even respirations
- Nasal flaring
- Retractions
Zachary LaFontaine Objective Data
Objective Data Collection: 24.33 out of 25 (97.32%)
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– Correct
– Partially correct
– Incorrect
– Missed
Growth Chart: Head Circumference
– Head Circumference Percentile (1/2 point)
– Below 5th percentile
– Between 5th and 95th percentile
– Above 95th percentile
– Head Circumference Growth Curve (1/2 point)
– Growth curve maintained
– Growth curve decline
Growth Chart: Weight and Length
– Length Percentile (1/6 point)
– Below 5th percentile
– Between 5th and 95th percentile
– Above 95th percentile
– Length Growth Curve (1/6 point)
– Growth curve maintained
– Growth curve decline
– Weight Percentile (1/6 point)
– Below 5th percentile
– Between 5th and 95th percentile
– Above 95th percentile
– Weight Growth Curve (No point)
– Growth curve maintained
– Growth curve decline
– Weight For Length Percentile (1/6 point)
– Below 5th percentile
– Between 5th and 95th percentile
– Above 95th percentile
– Weight For Length Growth Curve (1/6 point)
– Growth curve maintained
– Growth curve decline
Inspected Nose
– Nares Inspection (1/3 point)
– Pale
– Pink
– Erythematous
– Mucus (1/3 point)
– Thin white mucus present
– Thick yellow mucus present
– Nares (1/3 point)
– Patent
– Obstructed, not patent single-sided
Inspected Ears
– Inspection (1/2 point)
– Ears set appropriately
– Ears low set, posteriorly rotated
– Pinna (1/2 point)
– Pinna flexible
– Pinna stiff
Inspected Mouth
– Frenulum (1/4 point)
– Frenulum intact
– Frenulum thick
– Palate (1/4 point)
– Palate intact
– Palate open
– Tongue (1/4 point)
– Tongue smooth
– Tongue rough
– Uvula (1/4 point)
– Uvula midline
– Uvula absent
Inspected Skin
– Color (1/8 point)
– Cyanosis
– Jaundice
– Pallor
– Congruent with genetic background
– Texture (1/8 point)
– Smooth
– Rough
– Temperature (1/8 point)
– Warm
– Cool
– Skin Hydration (1/8 point)
– Elastic
– Tenting
– Sluggish turgor
– Lesions (1/8 point)
– No visible lesions
– Laceration/wounds
– Erythema
– Ecchymosis
– Birthmark
– Discolorations
Mucous Membrane: Hydration (1/8 point)
– Moist
– Dry
Mucous Membrane: Appearance (1/8 point)
– Intact
– Cracked
– Blistered
Mucous Membrane: Color (1/8 point)
– Pink
– Pale
– Erythematous
Inspected Diaper Area
– Inspect Skin Diaper Area (1/1 point)
– No lesions present
– Macerated
– Edema
– Erythema
Inspected Genitalia
– Appearance (1/5 point)
– Urethral meatus midline
– Hypospadias
– Ambiguous genitalia
– Palpation (1/5 point)
– Testes present bilaterally
– Testes not palpable
– Rugae (1/5 point)
– Smooth
– Rough
– Masses (1/5 point)
– No masses
– Mass palpable
– Swelling
– Circumcision (1/5 point)
– Circumcised
– Uncircumcised
Assessed Musculoskeletal: Barlow and Ortolani
– Barlow (1/2 point)
– Positive
– Negative
– Ortolani (1/2 point)
– Positive
– Negative
Assessed Eyes: Pupils
– Shape (1/3 point)
– Round
– Abnormal shape
– Light Reaction (1/3 point)
– No reaction to light
– Reacts to light symmetrically
– Reacts to light asymmetrically
– Opacity (1/3 point)
– Clear
– Cloudy
Assessed Eyes: Red Reflex
– Red Reflex (1/3 point)
– Absent
– Present
– Color (1/3 point)
– Equal color bilaterally
– Unequal color bilaterally
– Opacity (1/3 point)
– Opacity absent
– Opacity present
Assessed Eyes: Tracking
– Vision Screening (1/1 point)
– Follows object in both directions
– Does not follow object in both directions
Assessed Extremities
– Movement (1/2 point)
– Moves all extremities
– Does not move all extremities
– Symmetry (1/2 point)
– Movement symmetrical
– Movement asymmetrical
Assessed Grasp
– Grasp (1/3 point)
– Intact
– Not Evident
– Tone (1/3 point)
– Strong
– Weak
– Symmetry (1/3 point)
– Symmetrical
– Asymmetrical
– Absent
Assessed Moro Reflex
– Moro Reflex (1/2 point)
– Normal Response
– Weak response
– Absent response
– Hearing (1/2 point)
– Hearing intact
– Hearing absent
Assessed Tonic Reflex
– Neck Range Of Motion (1/2 point)
– Symmetrical
– Asymmetrical
– Absent
– Tonic Reflex (1/2 point)
– Present
– Absent
Assessed Pulse
– Pulse (1/2 point)
– Regular
– Irregular
– Amplitude (1/2 point)
– Equal bilaterally
– 0
– +1
– +2
– +3
Assessed Rooting Reflex
– Rooting Reflex (1/1 point)
– Normal response
– Weak response
– Absent response
Assess Sucking Reflex
– Sucking Reflex (1/2 point)
– Normal response
– Weak response
– Absent response
– Tongue Range Of
Zachary LaFontaine Objective Data
Objective Data Collection: 24.33 out of 25 (97.32%)
– Correct
– Partially correct
– Incorrect
– Missed
Growth Chart: Head Circumference
– Head Circumference Percentile (1/2 point)
– Below 5th percentile
– Between 5th and 95th percentile
– Above 95th percentile
– Head Circumference Growth Curve (1/2 point)
– Growth curve maintained
– Growth curve decline
Growth Chart: Weight and Length
– Length Percentile (1/6 point)
– Below 5th percentile
– Between 5th and 95th percentile
– Above 95th percentile
– Length Growth Curve (1/6 point)
– Growth curve maintained
– Growth curve decline
– Weight Percentile (1/6 point)
– Below 5th percentile
– Between 5th and 95th percentile
– Above 95th percentile
– Weight Growth Curve (No point)
– Growth curve maintained
– Growth curve decline
– Weight For Length Percentile (1/6 point)
– Below 5th percentile
– Between 5th and 95th percentile
– Above 95th percentile
– Weight For Length Growth Curve (1/6 point)
– Growth curve maintained
– Growth curve decline
Inspected Nose
– Nares Inspection (1/3 point)
– Pale
– Pink
– Erythematous
– Mucus (1/3 point)
– Thin white mucus present
– Thick yellow mucus present
– Nares (1/3 point)
– Patent
– Obstructed, not patent single-sided
Inspected Ears
– Inspection (1/2 point)
– Ears set appropriately
– Ears low set, posteriorly rotated
– Pinna (1/2 point)
– Pinna flexible
– Pinna stiff
Inspected Mouth
– Frenulum (1/4 point)
– Frenulum intact
– Frenulum thick
– Palate (1/4 point)
– Palate intact
– Palate open
– Tongue (1/4 point)
– Tongue smooth
– Tongue rough
– Uvula (1/4 point)
– Uvula midline
– Uvula absent
Inspected Skin
– Color (1/8 point)
– Cyanosis
– Jaundice
– Pallor
– Congruent with genetic background
– Texture (1/8 point)
– Smooth
– Rough
– Temperature (1/8 point)
– Warm
– Cool
– Skin Hydration (1/8 point)
– Elastic
– Tenting
– Sluggish turgor
– Lesions (1/8 point)
– No visible lesions
– Laceration/wounds
– Erythema
– Ecchymosis
– Birthmark
– Discolorations
Mucous Membrane: Hydration (1/8 point)
– Moist
– Dry
Mucous Membrane: Appearance (1/8 point)
– Intact
– Cracked
– Blistered
Mucous Membrane: Color (1/8 point)
– Pink
– Pale
– Erythematous
Inspected Diaper Area
– Inspect Skin Diaper Area (1/1 point)
– No lesions present
– Macerated
– Edema
– Erythema
Inspected Genitalia
– Appearance (1/5 point)
– Urethral meatus midline
– Hypospadias
– Ambiguous genitalia
– Palpation (1/5 point)
– Testes present bilaterally
– Testes not palpable
– Rugae (1/5 point)
– Smooth
– Rough
– Masses (1/5 point)
– No masses
– Mass palpable
– Swelling
– Circumcision (1/5 point)
– Circumcised
– Uncircumcised
Assessed Musculoskeletal: Barlow and Ortolani
– Barlow (1/2 point)
– Positive
– Negative
– Ortolani (1/2 point)
– Positive
– Negative
Assessed Eyes: Pupils
– Shape (1/3 point)
– Round
– Abnormal shape
– Light Reaction (1/3 point)
– No reaction to light
– Reacts to light symmetrically
– Reacts to light asymmetrically
– Opacity (1/3 point)
– Clear
– Cloudy
Assessed Eyes: Red Reflex
– Red Reflex (1/3 point)
– Absent
– Present
– Color (1/3 point)
– Equal color bilaterally
– Unequal color bilaterally
– Opacity (1/3 point)
– Opacity absent
– Opacity present
Assessed Eyes: Tracking
– Vision Screening (1/1 point)
– Follows object in both directions
– Does not follow object in both directions
Assessed Extremities
– Movement (1/2 point)
– Moves all extremities
– Does not move all extremities
– Symmetry (1/2 point)
– Movement symmetrical
– Movement asymmetrical
Assessed Grasp
– Grasp (1/3 point)
– Intact
– Not Evident
– Tone (1/3 point)
– Strong
– Weak
– Symmetry (1/3 point)
– Symmetrical
– Asymmetrical
– Absent
Assessed Moro Reflex
– Moro Reflex (1/2 point)
– Normal Response
– Weak response
– Absent response
– Hearing (1/2 point)
– Hearing intact
– Hearing absent
Assessed Tonic Reflex
– Neck Range Of Motion (1/2 point)
– Symmetrical
– Asymmetrical
– Absent
– Tonic Reflex (1/2 point)
– Present
– Absent
Assessed Pulse
– Pulse (1/2 point)
– Regular
– Irregular
– Amplitude (1/2 point)
– Equal bilaterally
– 0
– +1
– +2
– +3
Assessed Rooting Reflex
– Rooting Reflex (1/1 point)
– Normal response
– Weak response
– Absent response
Assess Sucking Reflex
– Sucking Reflex (1/2 point)
– Normal
response
– Weak response
– Absent response
– Tongue Range Of Motion (1/2 point)
– Normal response
– Absent response
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