Republic of the Philippines
Department of Health
Regional Health Field Office No. VII
DON EMILIO DEL VALLE MEMORIAL HOSPITAL
“PHILHEALTH ACCREDITED HEALTHCARE PROVIDER”
ISO 9001:2015 QMS CERTIFIED
NEWBORN RECORD
(Fill up/Tick pertinent data)
Baby ☐Boy ☐Girl
_________________________________
Patients Family Name
___________________________________
Mother’s First Name/ Maiden Name/ Age
MATERNAL HISTORY NATAL HISTORY
Age _____ G___P___ Antenatal steroids given ☐Yes, doses______ ☐No ☐NA
(T___P___A___L___) Date labor started ______ Time ______ AM/PM
LMP_____ ☐sure of menses ☐unsure of Date delivered ______ Time ______ AM/PM
menses
First prenatal check up at ___ months AOG, no. of Manner of Delivery
visits ______ ☐Vaginal ☐Normal
Consult with ☐OB ☐nurse ☐midwife ☐Assisted ☐Vacuum ☐Forceps
at ☐hospital ☐private clinic ☐lying in ☐local ☐Caesarian Section
health center Indication ___________________________
Supplements ☐Iron ☐Folic Acid ☐Multivitamins ___________________________
Vaccinations ☐TT ☐Others Anesthesia / Analgesia _________________
______________________
With Birth plan including Unang Yakap ☐Yes Presentation ☐Cephalic ☐Breech
☐No
Assisted by ☐Doctor ☐Nurse ☐Midwife
Heredofamilial Disease ☐Others_________________
☐Diabetes ☐Epilepsy ☐Hypertension
☐Neurological Disease EINC
☐Cardiovascular ☐Thyroid ☐Renal ☐TB First 30 seconds of life
☐Others _______________ ☐Dried thoroughly and checked breathing of the baby
☐Assisted in skin to skin contact
Maternal Illness
Condition AOG Detected Treatment One minute to 3 minutes
Fever ☐Felt for cord pulsations, clamped, cut cord
Rashes ☐Returned baby to prone position
URTI
UTI Fifteen to 90 minutes
Hypertension ☐Supported first full breastfeed, time initiated ________
Preeclampsia ☐Monitored as a DYAD every 15 minutes
Eclampsia ☐Eye care done
Hyperthyroid
Hypothyroid
Diabetes ☐Did thorough physical exam of baby including weight,
Allergies anthropometric measurements
Others ☐Injected vitamin K IM
☐Injected hepatitis B vaccine IM
☐Injected BCG vaccine ID
Laboratories
☐Transported the mother and her baby to room together, time
AOG Performed Result roomed in ________
HBSAg
RPR
> Six hours
Blood type
☐Breastfeeding support on positioning provided
Ultrasound
Others
Complications of Pregnancy
Condition AOG Detected Treatment
Bleeding
Preterm
Labor
PROM
Others
ESTIMATION OF GESTATIONAL AGE BY MATURITY RATING
Republic of the Philippines
Department of Health
Regional Health Field Office No. VII
DON EMILIO DEL VALLE MEMORIAL HOSPITAL
“PHILHEALTH ACCREDITED HEALTHCARE PROVIDER”
ISO 9001:2015 QMS CERTIFIED
MATURITY
RATING
Name: _______________________________ WEEKS SCORE
Gestational Age by Dates: _____________________ weeks
Birthdate : __________________Hour ___________AM/PM 20 -10
APGAR Score: _______________ 1 min __________ 5 min
22 -5
24 0
26 5
NEUROLOGIC MATURITY
28 10
30 15
32 20
34 25
CHECK EMAIL 36 30
38 35
40 40
42 45
44 50
PHYSICAL MATURITY SCORING SECTION
ESTIMATED GESTATIONAL AGE 1ST EXAM= X 2ND EXAM= 0
BY MATURITY RATING
DATE _______WEEKS _____WEEKS
CHECK EMAIL TIME OF EXAM _____AM/PM _____AM/PM
AGE OF EXAM ______HOURS ______HOURS
SIGNATURE OF EXAMINER _________M.D _________M.D
Republic of the Philippines
Department of Health
Regional Health Field Office No. VII
DON EMILIO DEL VALLE MEMORIAL HOSPITAL
“PHILHEALTH ACCREDITED HEALTHCARE PROVIDER”
ISO 9001:2015 QMS CERTIFIED
HEIGHT
HEAD CIRCUMFERENCE
WEIGHT
1ST EXAM(X) 2ND EXAM(0)
LARGE FOR GESTATIONAL AGE(LGA)
APPROPRIATE FOR GESTATIONAL
AGE(AGA)
SMALL FOR GESTATIONAL AGE (SGA)
AGE AT EXAM ______HOUR ______HOURS
S
SIGNATURE OF EXAMINER ________M.D ________M.D
Republic of the Philippines
Department of Health
Regional Health Field Office No. VII
DON EMILIO DEL VALLE MEMORIAL HOSPITAL
“PHILHEALTH ACCREDITED HEALTHCARE PROVIDER”
ISO 9001:2015 QMS CERTIFIED
Republic of the Philippines
Department of Health
Regional Health Field Office No. VII
DON EMILIO DEL VALLE MEMORIAL HOSPITAL
“PHILHEALTH ACCREDITED HEALTHCARE PROVIDER”
ISO 9001:2015 QMS CERTIFIED
NEWBORN EXAMINATION
Weight _________________grams Normal x Abnormal
Length __________________cm
____ 1. General appearance (posture, activity)
Head Circumference _______cm ____ 2. Maturity
Chest Circumference _______cm ____ 3. Skin, mucous membranes
Abdominal Circumference _______cm ____ 4. Head
a. Fontanels, sutures
b. Facies
c. Eyes
APGAR 0 1 2 d. Ears, nose, throat
Appearance Blue or Blue Pink all _____ 5. Neck, clavicles
pale all extremities over _____ 6. Chest (thorax, breast)
over pink body a. Heart
b. Lungs
Pulse None >100 ≤ 100 _____ 7. Abdomen
a. Liver, kidneys, spleen
Grimace No Weak Coughs, b. Cord vessels
response grimace sneezes, _____ 8. Pireneum (anus, genitalia)
when cries or _____ 9. Back
stimulated pulls away _____ 10 Extremities
when a. Hips
stimulated b. Pulses
Activity None Some Active _____ 11. Others
flexion of Arms
extremities flexed legs
resist
extension
Respirations None Slow/weak Strong cry
irregular
gasping
Resuscitation Done YES NO
APGAR Score__________________
Admitting Pediatrician _____________________________
1 min 5 min 10 min 15 min 20 min Attending Pediatrician _____________________________
A
Obstetrician _____________________________________
P
Nurse on Duty ___________________________________
G
Impression ______________________________________
A
________________________________________________
R
________________________________________________
Score
________________________________________________
________________________________________________
________________________________________________
Republic of the Philippines
Department of Health
Regional Health Field Office No. VII
DON EMILIO DEL VALLE MEMORIAL HOSPITAL
“PHILHEALTH ACCREDITED HEALTHCARE PROVIDER”
ISO 9001:2015 QMS CERTIFIED
HISTORY
(Fill up/tick pertinent data)
Baby Boy Girl_______________ Admitted for ______________ Date ______________
Date Delivered _____________________ Time Admitted _______________________
Maternal Age _____ G ____P ____(T ______P ______A ____L ______)
Prenatal First PNCU started at ____ months AOG, with ___(no) prenatal visit with OB Nurse Midwife
At OPD Private Clinic lying in clinic local health center
Medical smoker alcoholic beverage drinker HPN DM BA Allergies, specify __________
Other illness ____________________________________________________________________________
Antibiotics ______________________________________________________________________________
Antenatal steroids ______________________________________________________________________________
Supplements __________________________________________________________________________________
Other medications ______________________________________________________________________________
Laboratory Results Ultrasound ____________________________________________________________________
Other laboratories ______________________________________________________________________________
Natal
Delivered Vaginal
Assisted Vacuum Forceps
CS Indication ________________________________________________________
Anesthesia/ Analgesia ________________________________________________________
Presentation Cephalic Breech
Receieved 1. Term Breech
2. Vigorous Preterm looking
3. Good cry Limp
4. Meconium Regular respirations
Placenta Complete Macerated Infarted, ________%
Placentation in multiple gestation ___________________________
Estimated Blood Loss ______________ ml
Time
Intervention Drying, tactile stimulation, thermoregulation initiated _________________
Assesment HR _____ RR _____ Color_____ T ______
Interim History (for initially well babies, roomed in)
1 5 10 15 20
A
P
G
A
R
Score
Republic of the Philippines
Department of Health
Regional Health Field Office No. VII
DON EMILIO DEL VALLE MEMORIAL HOSPITAL
“PHILHEALTH ACCREDITED HEALTHCARE PROVIDER”
ISO 9001:2015 QMS CERTIFIED
Republic of the Philippines
Department of Health
Regional Health Field Office No. VII
DON EMILIO DEL VALLE MEMORIAL HOSPITAL
“PHILHEALTH ACCREDITED HEALTHCARE PROVIDER”
ISO 9001:2015 QMS CERTIFIED
PHYSICAL EXAMINATION
Examined _________________________________________________________________________________
Weight ____________________ grams Head circumference ___________cm
Length ____________________ cm Chest circumference ___________ cm
Abdominal circumference ___________ cm
HR ________ RR _________ T __________ O2 saturation _________
Skin ______________________________________________________________________________________
HEENT ____________________________________________________________________________________
Chest and Lungs ____________________________________________________________________________
Heart _____________________________________________________________________________________
Abdomen __________________________________________________________________________________
Umbilicus __________________________________________________________________________________
Back ______________________________________________________________________________________
Genitalia ___________________________________________________________________________________
Extremities _________________________________________________________________________________
Impression
Full Term Preterm _____ weeks by pediatric aging , ______ grams AGA SGA LGA, delivered via
Spontaneous vaginal delivery assisted vaginal delivery caesarean section secondary to _____________
Cephalic breech, live baby boy girl, APGAR score __________
Other _________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
Other interventions
Continued drying, tactile stimulation, thermoregulation
CPAP
O2 inhalation
Positive pressure ventilation
Corrective steps Mask, correct size
Reposition
Suction secretions
Open airway
Pressure increased
Alternate airway Intubation ET size____ level ____
Republic of the Philippines
Department of Health
Regional Health Field Office No. VII
DON EMILIO DEL VALLE MEMORIAL HOSPITAL
“PHILHEALTH ACCREDITED HEALTHCARE PROVIDER”
ISO 9001:2015 QMS CERTIFIED
