AGNO3 (Silver Nitrate) Breast Milk Neosporin Unknown EES None Colostrum Other (Specify)______________ Boric Acid Abnormal conditions of the newborn (Check all that apply): None newborn for suspected neonatal Assisted ventilation required sepsis immediately following Seizure or serious neurologic delivery dysfunction Assisted ventilation required Significant birth injury (skeletal for more than six hours fracture(s), peripheral nerve NICU admission injury, and/or soft tissue/solid Newborn given surfactant organ hemorrhage which requires replacement therapy intervention) Antibiotics received by the (Check all that apply): Congenital anomalies of the newborn None disease Hirshsprung’s Anencephaly Congenital hip dislocation Craniofacial Anomalies Amniotic bands Meningomyelocele / Spina bifida Limb reduction defect Hydrocephalus w/o Spina bifida Congenital cataract Encephalocele Cleft Lip with/without Cleft Palate Microcephalus Cleft Palate alone Cyanotic congenital heart disease Down Syndrome Karyotype pending – Tetralogy of Fallot Down Syndrome confirmed –Karyotype Congenital diaphragmatic hernia Suspected chromosomal disorder – Omphalocele Karyotype confirmed Gastroschisis Suspected chromosomal disorder Bladder exstrophy Karyotype pending Rectal/large intestinal Hypospadias atresia/stenosis Was infant transferred within 24 hours of delivery? Yes* No *If Yes, enter the name of the facility infant was transferred to: ____________________________________________________ Other (specify): ________________________________________ Is infant living at time of report? Yes No Infant transferred, status unknown If No, complete a death record.
AGNO3 (Silver Nitrate) Neosporin EES Colostrum Boric Acid Breast Milk Unknown None Other (Specify)______________ Abnormal conditions of the newborn (Check all that apply): None Assisted ventilation required immediately following delivery Assisted ventilation required for more than six hours NICU admission Newborn given surfactant replacement therapy Antibiotics received by the newborn for suspected neonatal sepsis Seizure or serious neurologic dysfunction Significant birth injury (skeletal fracture(s), peripheral nerve injury, and/or soft tissue/solid organ hemorrhage which requires intervention) Congenital anomalies of the newborn (Check all that apply): None Anencephaly Craniofacial Anomalies Meningomyelocele / Spina bifida Hydrocephalus w/o Spina bifida Encephalocele Microcephalus Cyanotic congenital heart disease Tetralogy of Fallot Congenital diaphragmatic hernia Omphalocele Gastroschisis Bladder exstrophy Rectal/large intestinal atresia/stenosis Hirshsprung’s disease Congenital hip dislocation Amniotic bands Limb reduction defect Congenital cataract Cleft Lip with/without Cleft Palate Cleft Palate alone Down Syndrome – Karyotype pending Down Syndrome –Karyotype confirmed Suspected chromosomal disorder – Karyotype confirmed Suspected chromosomal disorder Karyotype pending Hypospadias Was infant transferred within 24 hours of delivery? Yes* No *If Yes, enter the name of the facility infant was transferred to: ____________________________________________________ Other (specify): ________________________________________ Is infant living at time of report? Yes No Infant transferred, status unknown If No, complete a death record.
Facility_Worksheet.10.2014.docx