Newborn Assessment
Created by
Lisa Shah
Specialty
Paediatrician
Last edited
10/20/2026
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0 times
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About this template
A structured template for documenting a newborn’s birth and nursery course, feeding and weight status, home safety, and early developmental behaviors. It supports a thorough assessment during the first days after birth and clear communication with caregivers.
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Kai Nakamura is a 4-day-old newborn.
Birth And Nursery
The infant was delivered at KMCWC (Kapiolani) and went home on 18/05/2024.
39 2/7 weeks by NSVD.
Mother G1, P1. Maternal laboratory results were unremarkable. Maternal history and the pregnancy were unremarkable.
The infant passed CCHD screening. Passed the hearing screen.
The infant received Hep B immunization, vitamin K, and erythromycin.
24-hour TCB was 4.2 mg/dL (low intermediate risk zone); no phototherapy required.
Feeding And Weight
Birth weight was 3,420 g. Today's weight is 3,240 g, a 5.3 % decrease from birth weight.
The infant has been breastfeeding for 15 minutes every 2-3 hours.
Infant latches well bilaterally. Mother's milk came in today, and she is comfortable with feeding progress.
5 wet diapers and 4 yellow, seedy stools over the past 24 hours, which is adequate.
Household And Safety
Household members: Mother, father, and maternal grandmother.
The infant sleeps on the back in a separate crib.
The infant has a rear-facing car seat positioned in the vehicle's back seat.
The baby is currently able to
- Remain awake briefly for feeding.
- Make short periods of eye contact.
- Cry when uncomfortable.
- Settle in response to an adult voice.
- Briefly lift and turn the head to one side while prone.
- Move both arms and legs together when startled.
- Keep the hands closed in fists and grasp reflexively.
How to use this template
This template can be used to assist with various tasks in the medical field. You can use it to generate notes, manage patient information, or assist with diagnosis and the Assessment and Plan. To use this template, simply click the “Use Template” button above. If you have any questions or need assistance, feel free to reach out to the support team or refer to the description and example output provided above.