Infant Well Visit Shadow health documentation
This is a healthy 2-month-old baby seen with their mother for the appointment. The mother says the baby eats and sleeps well, interacts socially, and appears to have normal vision and hearing. Safety measures at home include smoke detectors, a safe sleeping environment, and constant adult supervision. The baby’s hygiene is good, and there are no issues with the diaper area.
Table of Contents
Details of the Visit
Today, we saw a 2-month-old baby boy for a checkup. He was born vaginally at 39 weeks gestation, weighing 7lbs 4 oz, and measuring 19 inches. He had no complications at birth and is accompanied by his mother. He is not taking any medications, and there are no known allergies. He is breastfed 5-7 times a day for about 10 minutes on each breast, with variations due to his mother’s school schedule. He has minimal spitting up, has 5-6 wet diapers and 3 bowel movements per day, and sleeps approximately 16 hours on certain days. His developmental milestones include smiling, tracking objects with his eyes, cooing, turning to sounds, and lifting his head when on his stomach. The mother’s health is busy but generally good, although she reports insufficient sleep and full breasts before feeding. Safety measures include a rear-facing car seat, safe sleeping arrangements, and constant supervision at home.
Physical Examination Findings
The baby’s measurements are within normal ranges, with his head circumference, weight, and length all falling between the 5th and 95th percentiles. Vital signs are within normal limits. His head is symmetrical, fontanelles are normal, eyes are clear with a red reflex present, ears are aligned, nose and mouth are normal, neck has full range of motion, chest and lungs are clear, heart sounds are normal, abdomen is soft, and genitalia are normal. His skin is warm, smooth, and without lesions, and he demonstrates appropriate hearing and vision responses.
Assessment
Overall, the baby’s findings are normal for his age, with appropriate growth and development, normal physical exam findings, and no significant concerns.
Plan
The plan is to continue breastfeeding and schedule a follow-up appointment in 2 months unless issues arise. The mother’s health will be monitored, and vaccinations will be administered according to the CDC schedule. Specific instructions include surveillance for the next visit, continuing with breastfeeding and implementing a structured feeding schedule, consulting with a lactation specialist, ensuring safety measures, and providing anticipatory guidance for the baby’s development and care.
Infant Well Visit Shadow health documentation
My Provider Notes
| Student Documentation | Model Documentation |
|---|---|
SubjectiveThis is a well nourished 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, constant supervision of an adult. Hygiene of infant is good, diaper area normal. Infant Well Visit Shadow health documentation |
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 allergies Nutrition: 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.Infant Well Visit Shadow health documentation |
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 Infant Well Visit Shadow health documentation 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 Infant Well Visit Shadow health documentation |
AssessmentNormal findings for a 2 months old male baby. Head with normal development, normal size, and growing speed. Well nourished. No abnormal findings on cardiopulmonary systems. Ortho: Barlow and Ortolani were normal, no Signs pf hip problems. Moro reflex normal for the age. Infant Well Visit Shadow health documentation . 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: Infant Well Visit Shadow health documentation 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 |
