Shadow Health Assignments
Infant Well Visit Shadow health documentation
Student’s Records Model’s Documentation
Subjective
This is a healthy 2-month-old baby who came to the appointment with the mother. The mother reports that the baby’s feeding and sleeping patterns are normal. The baby interacts well socially, and there are no concerns about vision or hearing. Safety measures at home include smoke detectors, a safe sleeping place, and constant adult supervision. The baby’s hygiene is good, and the diaper area looks normal.
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Infant’s Checkup – Shadow Health Records
A 2-month-old male baby is here for a child checkup. He was born via vaginal delivery at 39 weeks gestation. His length is 19 inches and his weight is 7 pounds 4 ounces. His APGAR scores were 9 at 1 minute and 10 at 5 minutes. There were no complications during birth. The baby is accompanied by his mother. The baby is not taking any medications and has no known allergies. He is breastfed 5-7 times a day for about 10 minutes on each breast. His feeding schedule varies due to his mother’s school schedule. He has minimal spitting, 5-6 wet diapers a day, and usually 3 bowel movements a day with soft, mustard-yellow stool. His sleep pattern varies, with about 16 hours of sleep on certain days and different hours on other days. He smiles, tracks objects, coos, turns to sounds, and lifts his head when placed on his tummy. The mother is busy with school and has help caring for the baby. She eats healthily but lacks sufficient sleep. The baby’s safety measures include a rear-facing car seat and safe sleeping arrangements.
Objective
The baby’s growth is within normal ranges, with his head circumference, weight, and length falling between the 5th and 95th percentiles. His vital signs are all within normal limits. There are no abnormal findings in the nose, ears, mouth, or skin.
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
The baby is calm and alert during the examination. His head is symmetrical, fontanelles are smooth and flat, and he has thin hair. His eyes open spontaneously, lens is clear, red reflex is present, and he responds to light. His ears are aligned and flexible, and he turns his head towards sounds. The nose is pink and patent, with thin white mucus present. The mouth and throat are normal. The neck has full range of motion. The chest rises and falls symmetrically during breathing, and the lungs are clear. The cardiovascular system is normal with regular heart sounds. The abdomen is soft and non-tender. Genitalia and extremities are normal. The baby’s reflexes, skin condition, and hearing/vision responses are all within normal range.
Assessment
The baby is developing well, with normal growth, head size, and overall health for a 2-month-old male baby. There are no concerns in the cardiopulmonary system. Orthopedic assessments for hip issues were normal, and the Moro reflex is as expected for his age. He is meeting milestones appropriate for his age and development.
Plan
The baby should continue breastfeeding. The next appointment is scheduled in 2 months, unless there are any abnormal findings that require earlier attention. The mother’s physical and mental health should be monitored. Vaccinations should be administered as per CDC guidelines.
For the next visit, the baby will receive daily vitamin D drops and continue breastfeeding. A structured feeding schedule should be developed to supplement breastfeeding during the mother’s school hours. Consultation with a lactation specialist is advised for improved feeding practices and schedules. Safety measures should be maintained, including safe sleeping practices. Vaccinations for HepB, RV, DTaP, PCV13, IPV, and HiB were administered during this visit. Minor fussiness and a low-grade fever might occur as a result. Any high fevers or vaccine reactions should be reported. Immediate medical attention is needed if breathing difficulties arise. The baby should return for a weight check in 3-4 weeks and for the 4-month well child visit. Anticipatory guidance includes encouraging social interactions, language development, and self-help skills. Parents should engage in holding, cuddling, talking, and singing to the baby. Reading is important for brain development. Pay attention to the baby’s sleep cues, establish a schedule, and practice tummy time. Avoid shaking or hitting the baby. Nutrition should be exclusively breast milk at this stage. Anticipate 5-6 wet diapers and 3-4 stools per day. Continue prenatal vitamins and a healthy diet for the mother. Safety measures include a rear-facing car seat and proper water heater settings. The baby should not be left alone, especially as he begins to roll.
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 Dont wait until the last minute.Provide your requirements and let our native nursing writers deliver your assignments ASAP. |