Neonatal Assessment Form

The Neonatal Assessment Form provides a structured framework for documenting the systematic evaluation of newborns from the delivery room through the initial nursery or NICU admission period. It captures the APGAR scoring system at 1 and 5 minutes (with extended 10-minute scoring when indicated) across all five domains — Appearance (skin color), Pulse (heart rate), Grimace (reflex irritability), Activity (muscle tone), and Respiration (respiratory effort). The form also documents Ballard Score components for gestational age determination, including neuromuscular maturity (posture, square window, arm recoil, popliteal angle, scarf sign, heel to ear) and physical maturity (skin, lanugo, plantar surface, breast, eye/ear, genitalia) assessments.

This template includes a comprehensive head-to-toe newborn physical examination checklist covering fontanelle assessment, red reflex examination, palate integrity, cardiac auscultation (murmur evaluation), respiratory status, abdominal examination (umbilical cord assessment, organomegaly), hip stability (Ortolani and Barlow maneuvers), extremity evaluation, primitive reflexes (Moro, grasp, rooting, sucking), and skin findings (jaundice, birthmarks, rashes). It also captures maternal history relevant to neonatal risk including GBS status, rupture of membranes duration, maternal medications, and prenatal screening results.

Designed for labor and delivery units, well-baby nurseries, neonatal intensive care units, and pediatric practices performing newborn follow-up visits, this form aligns with AAP Guidelines for Perinatal Care documentation standards. It supports quality measures for newborn screening completion, metabolic screen timing, hearing screen documentation, and critical congenital heart disease (CCHD) pulse oximetry screening, providing the comprehensive record needed for birth certificate completion and initial pediatric care coordination.