My Provider Notes
| Student Documentation | Model Documentation |
|---|---|
SubjectiveThis is a well nurished 2 month infant, at the appointment with mother. Mom reports normal feeding and sleeping patterns. Interacts socially. Seems to have vision and audition normal. Safety measures at home, smoke detectors, safe at the place to sleep, cnstant supervision of an adult. Hygiene of infant is good, diaper area normal. |
2 month old male infant today for child check. Birth information male infant born via vaginal delivery at 39 weeks gestation. Length-19”, Weight-7lbs 4 oz, APGAR 9@ 1 min, 10 @ 5 min. There were no birth complications. Here today accompanied by his mother. Medications: Currently not taking any medications, No known medication allergie.  Struggling to meet your deadline?Get your assignment on Zachary LaFontaine Shadow health Objective data done by certified MDs and PhDs in the USA. ORDER NOW! Nurse Loan Forgiveness by StateNutrition: Breastfeed 5-7 feeds/day about 10 min each breast, schedule varies by day due to mothers school schedule Elimination: Spitting-minimal, 5-6 wet diapers a day, usually 3 bowel movement per day soft, mustard yellow in nature Sleep: Sleeping about 16 hours on Mon-Wed-Fri, Unknown number of hours of sleep on Tuesday and Thursday as her mother cares for Zachary on these days while she is at school. He does wake up more frequently at night on Tuesday and Thursdays Development and behavior: Reports infant smiles, tracks objects with his eyes, coos, turns to noises and familiar sounds. Able to lift his head when on his tummy. Maternal Health: Reports a very busy schedule. Attends school two days a week and her mother helps care for Zachary when she is at school. Reports she does eat a healthy diet and drinks plenty of water. Does report insufficient sleep. Reported breasts feel full before feeding and don’t always feel empty after feeding. Denies any breast leaking. Safety: Car seat is rear facing in the back seat, Back to sleep on a cradleboard or in the bassinet in mothers bedroom, Daycare-not enrolled at this time, cared for at home by relatives. |
ObjectiveNormal growing curves: Head circ, wt and length, all above 5 and under 95 percentile. Vital signs WNL Nose, ears, mouth and skin, WNL, no abnormal findings. |
Vital signs: Length=55.2 cm, Weight=4.39 kg, Head circumference=38.1 cm, Temp=36.2C, Heart rate= 132/min, Resp=36 breaths/min General: Infant in mothers arms, calm and alert HEENT: Head: symmetrical, Anterior fontanelle smooth, soft, flat, Posterior fontanelle smooth, soft, flat thin hair Eyes: open spontaneously, lens clear, red reflex present, PERRL Ears: ears aligned with palpable fissures, pinna flexible, lobe formed appropriately, turns head towards sounds Nose: Nares pink, patent, thin white mucus present Mouth/Throat: Palate intact, tongue with full ROM, smooth, frenulum intact, uvula midline Neck: Neck with full ROM, lags when lifting body Resp: Symmetrical chest rise and fall, smooth even respirations, bilateral lungs clear to auscultation, CV: Regular rate and rhythm, S1S2 present, no murmurs, Pulse present, equal bilaterally Abd: Abdomen protuberant, soft, nontender, bowel sounds normoactive, umbilicus healed GU: Scrotum with smooth rugae, circumsized penis with urethral meatus midline, testes present bilaterally MSK: Bilateral extremities symmetrical, moves all extremities freely, Barlow and Ortolani negative. Neuro: Active, alert, sucking, rooting reflex intact, moro reflex intact, stepping reflex intact, tonic reflex intact and symmetrical, grasp reflex intact Skin: Warm, smooth, congruent with genetic background. Elastic turgor. No lesions noted, mucous membranes moist, pink and intact. diaper area without any rash. Hearing/Vision: Eyes track objects. Turns head to familiar voice |
AssessmentNormal findings for a 2 months old male baby. Head with normal development, normal size, and growing speed. Well nurished. No abnormal findingds on cardiopulmonary systems. Ortho: Barlow and Ortolani were normal, no Signs pf hip problems. Moro reflex normal for the age. Milestones within age for normal development. |
Well child check Feeding difficulties |
PlanContinue breastfeeding. Appointment in 2 months, unless needed before for abnormal findings. Monitor mother health, physical and mental. Vaccination as per CDC. |
Surveillance for next visit Vitamin D drops 400 IU 1 drop daily Continue with breastfeeding, develop a structured feeding schedule and begin using breast pump in between feedings so you have milk to supplement your infant when you are at school. Consultation with a lactation specialist to improve feeding practices, develop appropriate feeding schedules and provide support. Never leave unattended, Continue with back to sleep, Vaccines administered today-HepB, RV, DTaP, PCV13, IPV and HiB. Your infant may be a little fussy today and develop a low grade fever. Notify the office for any high fevers, vaccine site reactions, rashes. Call 911 if develops difficulty breathing Return for weight check in 3-4 weeks and then for 4 month old well child visit Anticipatory Guidance: Social Language & Self Help: Will begin to turn head towards familiar voices. Will look to parent to reassure him when he is upset. He will begin to associate you as the person who consoles him when he is upset. Verbal Language: Will begin making extended cooing sounds. Will become more organized. Gross Motor: Will begin to support self on elbow and wrists. Encourage tummy time to build upper body strength and neck strength. Will begin to roll from stomach to back Fine motor: Will begin to notice he has fingers and will grasp objects with his whole hand. Parent and family health: Make sure you have your postpartum check up. Take time to care for yourself. Infant behavior: Hold, cuddle, talk and sing to your infant. It is a good time to start reading to help with brain development. Pay attention to your infant’s cues for sleep. Keep a schedule. Tummy time throughout the day when awake. Find calming techniques he will respond to. Important to never shake or hit your baby. Nutrition: It is too early for any food other than breast milk. Anticipate 5-6 wet diapers a day and 3-4 stools per day. Continue your prenatal vitamin and a healthy diet. Safety: Continue with rear-facing infant seat in the backseat. Set your water heater to 120 degrees F. Do not leave your infant alone. As he begins to roll, you will need to keep a hand on him when on the changing table, etc. |
Infant Well Visit Shadow Health Documentation
My Provider Notes
Student Documentation Model Documentation
Subjective
Today, I saw a healthy 2-month-old baby during the well-child checkup. The mother reported that the baby has normal feeding and sleeping patterns, is socially interactive, and appears to have normal vision and hearing. The home environment is safe, with smoke detectors and a secure sleeping place. The baby’s hygiene, especially the diaper area, is good.
I conducted a checkup on a 2-month-old baby boy. He was born via vaginal delivery at 39 weeks of gestation, and his birth was uncomplicated. The baby’s mother was present during the visit. The baby is not currently taking any medications, and there are no known allergies to medications. He is breastfed 5-7 times a day, with each feeding lasting about 10 minutes. The feeding schedule varies based on the mother’s school schedule. The baby has minimal spitting and wets 5-6 diapers a day, with approximately 3 bowel movements, which are soft and mustard yellow. His sleep pattern varies during the week, with longer sleep on certain days. The baby shows developmental milestones, such as smiling, tracking objects with his eyes, cooing, and lifting his head during tummy time. The mother has a busy schedule, attends school two days a week, maintains a healthy diet, and drinks plenty of water, but she experiences insufficient sleep. Her breasts feel full before feeding and not always empty after. She does not report any breast leaking. Safety measures include a rear-facing car seat, safe sleeping positions, and constant supervision at home.
Objective
The baby’s growth is within normal ranges, with head circumference, weight, and length percentiles between 5 and 95. Vital signs are within normal limits, and there are no abnormalities in the nose, ears, mouth, or skin.
During the examination, the baby’s vital signs were measured. His length is 55.2 cm, weight is 4.39 kg, head circumference is 38.1 cm, temperature is 36.2°C, heart rate is 132/min, and respiratory rate is 36 breaths/min. The baby appeared calm and alert while in his mother’s arms. His head is symmetrical, and both the anterior and posterior fontanelles are smooth, soft, and flat. The baby’s eyes open spontaneously, with clear lenses and a present red reflex. His ears are aligned with palpable fissures, and the pinna is flexible with appropriate lobe formation. The baby turns his head towards sounds. The nose has pink, patent nares with thin white mucus present. The mouth and throat show an intact palate, full range of tongue motion, a smooth tongue, intact frenulum, and a midline uvula.
The neck has full range of motion and lags when lifting the body. Respiratory examination reveals symmetrical chest rise and fall, smooth and even respirations, and clear lung sounds bilaterally. Cardiovascular findings include a regular rate and rhythm, the presence of both S1 and S2 heart sounds, and no murmurs. A pulse is present and equal bilaterally. The abdomen is protuberant, soft, and nontender, with normoactive bowel sounds and a healed umbilicus. The scrotum has smooth rugae, and the penis is circumcised with a midline urethral meatus and present testes bilaterally. Both of the baby’s extremities are symmetrical, with free movement in all of them. Tests for hip problems, such as Barlow and Ortolani, were negative. Neurological assessment shows that the baby is active, alert, and has intact reflexes. The skin is warm, smooth, and matches the genetic background. It has elastic turgor, with no visible lesions, and moist, pink, and intact mucous membranes. The diaper area is free from any rash. The baby’s hearing and vision appear normal, with his eyes tracking objects and turning towards familiar voices.
Assessment
The baby exhibits normal findings for a 2-month-old male infant. His head is developing normally, and his size and growth rate are appropriate. He is well-nourished, with no abnormalities in the cardiopulmonary systems. Orthopedic assessments, including Barlow and Ortolani tests, show no signs of hip problems. His reflexes are within the expected range for his age, and he is meeting developmental milestones.
Based on the assessment, the baby is healthy and developing normally for a 2-month-old male infant. His head is growing at a normal rate, and his overall development is on track. He is well-nourished and shows no abnormalities in his cardiopulmonary systems. Orthopedic tests for hip problems were negative, indicating no issues in that area. His reflexes are appropriate for his age, and he is meeting the expected developmental milestones.
Plan
The plan includes continuing breastfeeding, scheduling the next appointment in 2 months (unless needed earlier due to any abnormalities), monitoring the mother’s health, and administering vaccinations as per CDC guidelines.
The plan for the baby’s care includes continuing breastfeeding and scheduling the next appointment in 2 months unless any issues arise before that. It also involves monitoring the mother’s health, both physical and mental. Vaccinations will be administered according to the CDC guidelines.
Surveillance for the next visit includes providing Vitamin D drops (400 IU, 1 drop daily), continuing with breastfeeding, developing a structured feeding schedule, and using a breast pump between feedings to have milk for supplementing the baby when the mother is at school. A consultation with a lactation specialist is recommended to improve feeding practices, establish appropriate feeding schedules, and provide support. The baby should never be left unattended, and safe sleeping practices, such as placing the baby on his back, should continue. The vaccines administered during the visit include HepB, RV, DTaP, PCV13, IPV, and HiB. It’s noted that the baby may be a little fussy and develop a low-grade fever after the vaccines, and the office should be notified in case of high fevers, vaccine site reactions, or rashes. In case of difficulty breathing, 911 should be called. A weight check should be scheduled in 3-4 weeks, and the next well-child visit is planned for when the baby is 4 months old. Anticipatory guidance includes information on the baby’s social, language, and self-help development, as well as safety and nutrition recommendations for the baby and family.
For the next visit, surveillance includes providing Vitamin D drops at a dose of 400 IU with 1 drop daily. The plan is to continue breastfeeding, develop a structured feeding schedule, and use a breast pump to have milk available for supplementation while the mother is at school. A consultation with a lactation specialist is recommended to improve feeding practices and schedules and provide support. The baby should never be left unattended. Safe sleeping practices, such as placing the baby on his back, should continue. The vaccines administered during this visit include HepB, RV, DTaP, PCV13, IPV, and HiB. It’s important to note that the baby may be a little fussy and develop a low-grade fever after the vaccines. The office should be notified in case
of high fevers, vaccine site reactions, or rashes, and 911 should be called in case of difficulty breathing. A weight check is scheduled in 3-4 weeks, and the next well-child visit is planned for when the baby is 4 months old. Anticipatory guidance covers various aspects of the baby’s development, including social, language, and self-help milestones, as well as safety and nutrition recommendations for both the baby and the family.
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