template of frichmond usually used in pediatrics

1. Hospital No:
Name:
Age/Sex:
DOB:
Address:
Weight:
Height:
BSA:
CC:
HPI:
Working Dx:
PMH Date: HD:
BP: Ht:
HR: Wt:
RR:
T:
O2 Sat:
FH F
R
Birth I
Maternal C
Immunization H
Nutritional M
Developmental O
N
Social D
P

2. NEONATAL HISTORY
CLINICAL HISTORY
A. GENERAL DATA
A. IMMEDIATE NEONATAL PERIOD
a. APGAR SCORE
BALLARD’S SCORE
Neuromuscular Maturity:
Physical Maturity:
Maturity Ratting
OB history:
Prenatal History:
Natal History:
NAME OF PATIENT: HOSPITAL NUMBER:
AGE: CORRECTED AGE:
(IF APPLICABLE)
ADDRESS:
SEX: RELIGION: BIRTHPLACE:
ADDRESS: BIRTHDATE:
INFORMANT:
RELATIONSHIP:
RELIABILITY:
VITAL SIGNS 1 MINUTE 5 MINUTES
Cardiac Rate
Respiratory
Rate
Color
Response to
stimulation
Muscle Tone
Total
Family History:
Personal & Social Hx:
Maternal History:

3. Date: HD: Date: HD: Date: HD: Date: HD:
BP: Ht: BP: Ht: BP: Ht: BP: Ht:
HR: Wt: HR: Wt: HR: Wt: HR: Wt:
RR: RR: RR: RR:
T: T: T: T:
O2 Sat: O2 Sat: O2 Sat: O2 Sat:
S/O
F
R
I
C
H
M
O
N
D
P

4. Drug Name/
Classification
Mode of Action Therapeutic
Dose
Indication Contraindication Other Remarks

5. PHYSICAL EXAMINATION
General
Appearance
Vital Signs CR
RR
Temp
SO2
Anthropometric
Measurements
BW BL BSA
HC CC AC
Skin
HEENT
Chest
Breast
Heart
Abdomen
Genitalia
Anus
Extremities
Neurological
Examination

6. ASSESSMENT
PLAN
I. Diagnostics
II. Essential Intra-partum Newborn Care
III. Routine Newborn Care
IV. Vaccinations
V. Treatment
VI. Disposition