Zachary LaFontaine Infant Well Visit Shadow health documentation

Zachary LaFontaine Infant Well Visit Shadow health documentation

Subjective

A 2-month-old male infant presented today for a child check. He was born via vaginal delivery at 39 weeks gestation with the following birth details: Length – 19 inches, Weight – 7 pounds 4 ounces, APGAR scores of 9 at 1 minute and 10 at 5 minutes. There were no complications during birth. The infant is accompanied by his mother. Here are the details:

Medications: Currently not taking any medications, and no known medication allergies.

Nutrition: Breastfed 5-7 times a day, with each breastfeeding session lasting about 10 minutes. The feeding schedule varies due to the mother’s school schedule.

Elimination: Minimal spitting, 5-6 wet diapers per day, and usually 3 bowel movements per day, which are soft and mustard-yellow.

Sleep: The infant sleeps approximately 16 hours on Mondays, Wednesdays, and Fridays. The number of hours of sleep on Tuesdays and Thursdays is unknown, as the mother cares for Zachary on these days while she is at school. He tends to wake up more frequently at night on Tuesdays and Thursdays.

Development and Behavior: The infant smiles, tracks objects with his eyes, coos, and turns to noises and familiar sounds. He can lift his head when placed on his tummy.

Maternal Health:

The mother has a busy schedule, attending school two days a week, with her mother helping care for Zachary during her school days. She reports maintaining a healthy diet and staying hydrated but does express concerns about insufficient sleep. She also mentions that her breasts feel full before feeding and don’t always feel empty after feeding. There is no reported breast leaking.

Safety:

The car seat is rear-facing in the back seat, and the infant sleeps on a cradleboard or in the bassinet in the mother’s bedroom. Currently, the infant is not enrolled in daycare and is cared for at home by relatives.

Objective

Zachary LaFontaine’s Infant Well Visit Shadow Health Documentation

Vital Signs: Length – 55.2 cm, Weight – 4.39 kg, Head circumference – 38.1 cm, Temperature – 36.2°C, Heart rate – 132/min, Respiratory rate – 36 breaths/min.

General: The infant is in the mother’s arms, calm, and alert.

HEENT (Head, Eyes, Ears, Nose, Throat):
– Head: Symmetrical, anterior fontanelle smooth, soft, and flat. Posterior fontanelle also smooth, soft, and flat with thin hair.
– Eyes: Open spontaneously, clear lens, red reflex present, and pupils react to light.
– Ears: Ears are aligned with palpable fissures, pinna is flexible, and the lobe is formed appropriately. The infant turns his head towards sounds.
– Nose: Nares are pink, patent, with thin white mucus present.
– Mouth/Throat: Palate is intact, tongue has full range of motion, smooth, frenulum is intact, and uvula is midline.
– Neck: Neck has full range of motion, lags when lifting the body.

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Respiratory:
– Symmetrical chest rise and fall, smooth and even respirations, with clear breath sounds in both lungs.

Cardiovascular:
– Regular rate and rhythm, S1S2 present, and no murmurs. Pulse is present and equal bilaterally.

Abdomen:
– Abdomen is protuberant, soft, non-tender, with normoactive bowel sounds. The umbilicus is healed.

Genitourinary:
– Scrotum has smooth rugae, and the circumcised penis has the urethral meatus midline, with testes present bilaterally.

Musculoskeletal:
– Bilateral extremities are symmetrical, and the infant moves all extremities freely. Barlow and Ortolani tests are negative.

Neuro:
– The infant is active, alert, with intact sucking, rooting reflex, moro reflex, stepping reflex, and tonic reflex. All reflexes are intact and symmetrical.

Skin:
– The skin is warm, smooth, congruent with genetic background, and has elastic turgor. No lesions are noted, mucous membranes are moist, pink, and intact. The diaper area is without any rash.

Hearing/Vision:
– Eyes track objects, and the infant turns his head toward familiar voices.

Assessment

The assessment reveals normal findings for a 2-month-old male infant. His head has normal development, size, and growth rate. He is well-nourished, and there are no abnormalities in the cardiopulmonary systems. Orthopedic assessments, including Barlow and Ortolani tests, are normal, with no signs of hip problems. The moro reflex is normal for his age, and he is achieving milestones within the expected range for normal development.

Plan

The plan includes the following recommendations:

– Continue breastfeeding.
– Schedule an appointment in 2 months unless there are abnormal findings that require an earlier visit.
– Monitor the mother’s health, both physical and mental.
– Administer vaccinations as per CDC guidelines.
– Perform surveillance for the next visit.
– Provide Vitamin D drops (400 IU, 1 drop daily).
– Continue with breastfeeding and develop a structured feeding schedule. Consider using a breast pump in between feedings to have milk available for supplementation when the mother is at school.
– Consultation with a lactation specialist to improve feeding practices, establish appropriate feeding schedules, and provide support.
– Emphasize never leaving the infant unattended.
– Maintain the practice of back to sleep.
– Administer vaccines today, including HepB, RV, DTaP, PCV13, IPV, and HiB. Expect the infant to be a little fussy and possibly develop a low-grade fever. Instruct the mother to notify the office for high fevers, vaccine site reactions, or rashes. In case of difficulty breathing, advise her to call 911.
– Schedule a weight check in 3-4 weeks and plan for the 4-month-old well-child visit.

Anticipatory Guidance:

Social Language & Self-Help:
– The infant will begin to turn his head towards familiar voices.
– He will look to the parent for reassurance when upset and begin to associate the parent as the source of comfort.

Verbal Language:
– The infant will start making extended cooing sounds and become more organized.

Gross Motor:
– He will begin to support himself on his elbows and wrists. Encourage tummy time to build upper body and neck strength. He will also start to roll from stomach to back.

Fine Motor:
– The infant will become aware of his fingers and start grasping objects with his whole hand.

Parent and Family Health:
– Ensure the mother has her postpartum checkup and takes time to care for herself.

Infant Behavior:
– Encourage holding, cuddling, talking, and singing to the infant. Begin reading to promote brain development. Pay attention to the infant’s cues for sleep, maintain a schedule, and incorporate tummy time when awake. Use calming techniques, but never resort to shaking or hitting.

Nutrition:
– Continue with exclusive breastfeeding. Expect 5-6 wet diapers a day

My Provider Notes

Student Documentation	Model Documentation
Subjective Zachary LaFontaine 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: Zachary LaFontaine Infant Well Visit Shadow health documentation 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. Zachary LaFontaine Infant Well Visit Shadow health documentation
Objective Zachary LaFontaine 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 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 Zachary LaFontaine Infant Well Visit Shadow health documentation
Assessment Normal 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. Zachary LaFontaine Infant Well Visit Shadow health documentation Milestones within age for normal development.	Well child check Feeding difficulties
Plan Continue breastfeeding. Appointment in 2 months, unless needed before for abnormal findings. Monitor mother health, physical and mental. Vaccination as per CDC. Zachary LaFontaine Infant Well Visit Shadow health documentation	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. Zachary LaFontaine Infant Well Visit Shadow health documentation. 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. Pa Zachary LaFontaine Infant Well Visit Shadow health documentationrent 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. Zachary LaFontaine 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. Start My Order